Registered Nurse Care Manager

Intermountain Health•St. George, UT

2d•$41 - $62•Onsite

About The Position

The Nurse Care Manager works collaboratively with physicians and other health care team members to improve the health of patients with chronic conditions or complex needs. The role educates patients and families to help them manage health care needs, facilitates communication, coordinates services, addresses barriers, and promotes optimal resource allocation while balancing clinical quality and cost management. This role works in an ambulatory setting. It may support three or more clinics in a general care manager model focused on designated Primary Care Clinical Program initiatives, or work with one or two clinics in a Personalized Primary Care model with a broader scope for a defined patient population. Patient interactions may be in person, by telephone, or through other electronic means. The Nurse Care Manager performs case management and patient evaluations, supports chronic disease management, coordinates care, and helps patients with self-management and behavior change. The role also supports population health, disease registries, preventive care, team-based care, care transitions, referral tracking, advanced care planning, and personalized primary care goals.

Requirements

Current RN license for the state in which the nurse practices.
BLS certification for healthcare providers.
Three years of clinical nursing experience.
RNs hired or promoted into this role must have or obtain a BSN within three years of hire or promotion.
Ability to see and read information, labels, and monitors; identify equipment and supplies; and assess patient needs.
Ability to verbally communicate and to hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergencies.
Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy, including frequent computer use and typing for patient care documentation and information access.

Nice To Haves

Bachelor's degree in Nursing (BSN) from an accredited institution; degree will be verified.
Experience in case management, utilization review, or discharge planning.
Cardiac background.

Responsibilities

Respond to physician referrals and identify patients who meet established care management criteria.
Assess patients’ family, social, and cultural characteristics; communication needs; behavioral and family risk factors; barriers; chronic disease risks; and understanding of medication treatment.
Use established care process models and applicable standards of care to manage chronic conditions.
Provide focused patient education using established content and tools.
Use clinician-approved, appropriately documented standing orders.
Develop individualized care plans and treatment goals with patients, consistent with the medical plan of care, and review progress and barriers at relevant visits.
Coordinate with care managers in other settings as appropriate.
Inform patients about enabling services, community agencies, recommended or available services, and how to contact them; maintain contact information for key community service agencies.
Use motivational interviewing and coaching to assess readiness for change, capacity and confidence for self-care, and adoption of healthy behaviors.
Develop self-care plans with patients, provide self-monitoring tools, and connect patients with support programs.
Assess and arrange treatment for mental health and substance abuse problems.
Establish processes to monitor patient adherence to medical plans of care and focus on prevention measures consistent with guidelines and care process models.
Review and manage quality reports related to chronic disease and prevention, and support clinicians in achieving quality incentives.
Collaborate with referring physicians and other members of the care team.
Complete pre-visit planning, including chart review and notifying patients about tests needed before visits.
Facilitate advanced care planning, including advanced directives, and establish processes for reminder letters and phone calls.
Support clinicians and teams in achieving personalized primary care goals.
Facilitate care transitions, including after unscheduled hospital admissions, emergency department visits, and skilled nursing home stays.
Track critical referrals and follow up to obtain reports from referral clinicians.
Collaborate with clinicians to establish written care plans for patients transitioning from pediatric to adult care.
Provide information on health insurance resources.
Supervise and support Health Advocates.
Attend clinic team and medical home meetings to assist with process design and resolution of team issues; support meeting agenda development and regularly review data summaries.