Population Health RN Case Manager – Family Medicine, Centerfield

University of Colorado•Hybrid, CO

6d•$83,794 - $95,000•Hybrid

About The Position

The RN Case Manager works collaboratively with physicians, interdisciplinary teams, patients, and families to promote positive patient outcomes through transitions of care and longitudinal care management. The RN Case Manager performs comprehensive assessments, develops individualized care plans, coordinates services across the continuum of care, and supports patients in achieving their health goals. The RN Case Manager serves as the primary clinical resource for high-risk patients and those recently discharged from acute care settings. In addition to nursing case management responsibilities, the role provides psychosocial support and assists patients with social determinants of health needs, including transportation, housing, food insecurity, financial assistance, and community resource referrals. Complex behavioral health and social work needs are escalated or referred appropriately.

Requirements

Bachelor’s degree in nursing, biological science, or a directly related field from an accredited institution.
Two (2) years of registered nurse experience in a clinical/hospital setting.
One (1) year of experience in case management in specialty area.
Applicants must meet minimum qualifications at the time of hire.
Applicants must be legally authorized to work in the United States without requiring sponsorship.
Registered Nurse (RN), State of Colorado.
Current Basic Life Support (BLS) for Healthcare Providers issued by American Heart Association or American Red Cross healthcare provider level CPR certification.
Maintains all required licensure and certifications for position.
Maintains all required continuing education requirements.
Must be able to work in-person or have reliable internet for remote work as approved.
Must be able to travel/cover to alternate locations as assigned.
Ability to communicate effectively, both in writing and orally.
Ability to establish and effective working relationships with employees at all levels throughout the institution.
Outstanding customer service skills.
Strong clinical assessment and care coordination skills.
Ability to build trusting relationships with patients and families.
Knowledge of community resources and social determinants of health.
Excellent communication and interdisciplinary collaboration skills.
Ability to prioritize and manage multiple high-risk patients.
Ability to analyze clinical information and support quality outcomes.
Commitment to patient-centered, whole-person care.
Ability to effectively communicate at all levels, to include physicians, leadership, and staff within the various affiliate organizations (UCH, Children’s Colorado, CU Medicine, CU SOM).
Ability to work within large, complex healthcare systems.
Ability to analyze and interpret data.

Nice To Haves

A combination of education and related technical/military/paraprofessional experience may be substituted for a bachelor’s degree on a year for year basis.
Three or more (3+) years registered nurse experience in a clinical/hospital setting.
Two or more (2+) years of experience in case management in specialty area.
Experience with transitions of care and ambulatory longitudinal care management.
Experience addressing social determinants of health and community resource coordination.
Experience in primary care, population health, or value-based care.
Bilingual, Spanish-speaking.
Nursing certification (ANCC) in specialty area.
Kronos, Epic, and Health Stream experience.

Responsibilities

Provide transitional care management following emergency department visits and hospital discharges.
Manage longitudinal care for high-risk and medically complex patients.
Perform comprehensive assessments and develop individualized care plans.
Monitor patient progress and modify care plans as needed.
Coordinate care across primary care, specialty care, hospitals, home health agencies, and community organizations.
Promote disease self-management, medication adherence, preventive care, and patient education.
Collaborate with providers and interdisciplinary teams to improve quality and value-based care outcomes.
Serve as a patient advocate and clinical liaison with outside agencies and healthcare partners.
Maintain accurate documentation and participate in quality improvement initiatives.
Assess psychosocial barriers affecting health outcomes.
Assist patients with access to transportation, housing, food resources, financial assistance, insurance programs, and other community resources.
Provide emotional support and crisis intervention within scope of practice.
Facilitate referrals to behavioral health, social work, and community-based organizations as appropriate.
Educate patients and families regarding available support services.
Collaborate with social workers, behavioral health providers, and community partners to address non-medical needs affecting health.