RN Care Manager

Intermountain Health

7d•$41 - $62•Onsite

About The Position

The RN Ambulatory Care Manager I delivers comprehensive ambulatory care management services to identified patients. The role uses clinical expertise to conduct care management screenings, assessments, and evaluations; develop and implement patient-centered care plans with shared goals and appropriate interventions; and coordinate effectively with patients, families and caregivers, healthcare providers, payers, community-based providers, and other involved parties. Work takes place across transitions of care, clinics, communities, and post-acute care settings, supporting proactive care for at-risk patients. The role promotes the mission, vision, and values of Intermountain Health and follows its service behavior standards. This is a full-time, 40-hour-per-week position, scheduled for day shifts Monday through Friday at West Lake Mead Clinic Primary in Henderson, Nevada.

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 this role must obtain a BSN within four years of hire or promotion.
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.
Proficiency in basic computer skills and Microsoft Office software.
For duties requiring home or community visits: current BLS certification, a current driver’s license, current auto insurance, an acceptable driving record, and reliable transportation.

Nice To Haves

Care Management Certification.
Demonstrated experience in case management, utilization review, or discharge planning.

Responsibilities

Identify patients for proactive intervention using screening criteria, medical record reviews, payer models, medical risk scores, or referrals.
Assess patients’ medical, functional, and social conditions in accordance with department policies and guidelines, including NCQA standards when appropriate.
Develop, maintain, monitor, and evaluate individualized patient care plans and outcomes; modify plans or interventions as appropriate.
Coordinate internal and external services for social determinants of health needs and community-based care, and connect patients with community resources.
Support patient self-management and behavior change through motivational interviewing and coaching; assess readiness and capacity for change and confidence in self-care.
Educate patients about medical and behavioral health conditions and self-management, and educate healthcare team members about case management processes and appropriate referrals.
Advocate for patient rights and collaborate with physicians and other healthcare team members to support timely, quality care and resolve delays or issues.
Participate in rounds and case conferences as needed, and use a team-based approach by consulting or referring to social work, nutrition, pharmacy, rehabilitation, behavioral health, and other resources.
Build and maintain partnerships with hospital care management, post-acute providers, and other care managers to support seamless transitions and continuity of care while avoiding duplicative services.
Participate in system and regional initiatives to improve transitions of care and avoid duplicative services.
Facilitate advanced care planning and participate in patient and family care conferences as appropriate.
Conduct root cause analyses 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 abide by service behavior standards.