Registered Nurse Triage and Transition

Intermountain Health

2d•$35 - $53

About The Position

The RN Transition and Triage Care Manager provides comprehensive, time-limited services to patients and families to support continuity of care across healthcare settings and clinicians. The role works to prevent complications, connect patients with resources, and guide them to appropriate levels of care. Using clinical expertise, technology, and evidence-based practices, the manager assesses, plans, implements, and evaluates patient care through telephone or digital communication. The role collaborates with patients, families, healthcare providers, payers, community-based providers, and other involved parties to provide efficient, effective, patient-centered care management. Work may involve triage, transitions of care, clinics, communities, and post-acute care environments. The position requires office hours aligned with the Pacific time zone. Ambulatory care experience in a primary care clinic, telephone triage, or telephonic nursing is strongly preferred. The role is based at the Peaks Regional Office in Broomfield, Colorado, with 40 scheduled hours per week.

Requirements

Current Registered Nurse (RN) license in the state of practice.
Bachelor of Science in Nursing (BSN) from an accredited institution; degree verification is required. RNs hired or promoted into the role must obtain a BSN within four years of the hire or promotion date.
Demonstrated clinical nursing experience in chronic disease management and familiarity with chronic disease terminology and processes.
Demonstrated understanding of disease management, including treatment, length of stay, barriers to care delivery, and variations in care.
Basic computer skills and knowledge of Microsoft Office software.
At least two years of nursing experience; new graduates are not being considered.
Ability to meet the physical requirements described, including seeing and reading information, communicating and hearing effectively, using manual dexterity for equipment and computer work, and potentially standing for extended periods.
For roles requiring driving, ability to drive a vehicle and observe signs, traffic signals, and other vehicles.

Nice To Haves

Bachelor of Science in Nursing (BSN) from an accredited institution.
Care Management Certification.
Experience in ambulatory transitions of care or telephonic triage.
Intermediate computer skills and knowledge of Microsoft Office software.
Ambulatory care experience in a primary care clinic, telephone triage, or telephonic nursing is strongly preferred.

Responsibilities

Identify patients for proactive intervention using screening criteria, medical record review, payer models, medical risk scores, or referrals.
Assess patients’ medical, functional, and social conditions under department policies and guidelines, and develop individualized care plans, recommendations, or referrals.
Coordinate internal and external services to address social determinants of health and community care needs.
Evaluate care plans and outcomes, and modify plans or interventions as appropriate.
Conduct remote nursing assessments of acute symptoms, applying critical thinking and evidence-based protocols to recommend appropriate care.
Support patient self-management and behavior change through health coaching, care navigation, care coordination, and education for patients, caregivers, and families.
Educate healthcare team members about transitions and triage processes, appropriate referrals, and patient advocacy; educate patients about medical and behavioral health conditions and self-management.
Collaborate with physicians and other healthcare team members to support timely, quality care and resolve delays or issues; participate in rounds or case conferences as needed.
Use a team-based approach and refer or consult with social work, nutrition, pharmacy, rehabilitation, behavioral health, and other resources as appropriate.
Build and maintain partnerships with hospital care management, post-acute providers, and other care managers to support seamless transitions and avoid duplicative services.
Participate in system and regional initiatives to improve transitions of care and prevent duplication of services.
Conduct root cause analysis of extended post-acute stays, inappropriate utilization, and readmissions; track key data and metrics.
Identify, analyze, and monitor industry, regulatory, technology, and market trends affecting ambulatory and post-acute services.
Promote Intermountain Health’s mission, vision, and values and follow service behavior standards.