Job Description

The Corewell Health West Ambulatory Care Management Department is made up of Social Workers, RN Care Managers, Community Health Workers and Medical Assistants. We have a large team of Social Workers and RN Care Managers who are embedded in Primary Care offices across the system. Care Management work is focused on identifying and connecting with patients who have behavioral health concerns or chronic medical conditions on an outpatient basis and assisting these patients with developing healthy behaviors and coping skills that will improve overall health outcomes. Our Ambulatory Care Managers play an active role on the patient’s care team and partner with primary care providers in developing an appropriate treatment approach for patients experiencing chronic disease and/or behavioral health concerns to promote self-management and symptom improvement. The Ambulatory Care Management team also provides comprehensive transitions of care support to patients who have been admitted to the hospital in an effort to keep patients well in the community, prevent readmissions and reduce overall cost of care. Resources and support for barriers related to Social Determinants of Health (SDoH) is also provided to primary care patients by our remote team of Community Health Workers. The Ambulatory Care Management Department has consistently demonstrated successful outcomes through the interventions provided to patients. Corewell Health operates over 300 outpatient clinics across Michigan, bringing a multitude of care options to the communities that we serve. There are over 40 different types of primary care and specialty practices, which allows those who work in these clinics the opportunity to learn and explore various interests or to specialize in one area. Plans and prioritizes care for individuals and population of clients, focusing on strategies that will promote optimal health within populations. Provides peer support and role modeling related to the development of life skills and health/wellness to individuals and families during home visits, if applicable. Demonstrates expertise, current knowledge in patient care and management of a caseload of clients of varying complexity and seeks to improve patient, family and health systems/community outcomes through the application of educational concepts/skills and preventive care in a managed care environment. Assesses internal referrals and may provide individual, short-term therapy services or care management services and monitors patient progress. Develops plan of care and makes recommendations to PCPs, specialists, and other members of the health care team regarding mental health treatment strategies and identifies strategies to maximize continuity of care across the continuum. Assesses and provides follow-up for the Systematic Case Review process which includes consultation with psychiatrist and serves as liaison between PCP and consulting psychiatrist to assist in psychotropic medication management for patients. Responds to patients’ urgent mental health concerns, including suicide risk assessments and assists patient in accessing appropriate level of care. Professional development opportunities through peer case review and monthly continuing education opportunities.

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