RN Care Manager

Intermountain Health

9d • Onsite

About The Position

The RN Ambulatory Care Manager I delivers comprehensive ambulatory care management services to identified patients. Leveraging clinical expertise, this role involves conducting care management screenings, assessments, and evaluations. The manager develops and implements patient-centered care plans with shared goals and appropriate interventions. Collaborating effectively with patients, families/caregivers, healthcare providers, payers, community-based providers, and other involved parties ensures efficient, effective, and patient-centered care management services. The role operates across various settings, including transitions of care, clinics, communities, and post-acute care environments, and supports proactive care for at-risk patients.

Requirements

• Current Registered Nurse (RN) license in state of practice.
• Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required).
• 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, identifying barriers to delivery of care and any variation.
• Proficiency in basic computer skills and Microsoft Office software.
• Caregivers whose duties require them to conduct home or community visits must maintain current BLS certification, have a current driver’s license, current auto insurance, an acceptable driving record and reliable transportation.

Nice To Haves

• Bachelor of Science in Nursing (BSN) from an accredited institution.
• Care Management Certification
• Demonstrated experience in case management, utilization review, or discharge planning.

Responsibilities

• Identifies patients for proactive interventions using specific screening criteria, medical record review, payor models, medical risk scores, or referrals.
• Assesses patients' medical, functional, and social conditions per department policy/guidelines to develop individualized care plans and connect them with community resources.
• Assesses patients per NCQA standards as appropriate.
• Develops, maintains, and monitors patient care plans consistent with NCQA and department policies/guidelines, ensuring adherence to medical plans and focusing on prevention measures.
• Coordinates internal and external services for SDoH needs and care in the community.
• Evaluates the effectiveness of the patient’s care plan and outcomes.
• Modifies the plan of care or specific interventions, as appropriate.
• Supports patient self-management and behavior change using motivational interviewing and coaching techniques.
• Assesses patient readiness and capacity for change and confidence in self-care.
• Educates healthcare team members about case management processes, appropriate referrals, and advocate for patient rights.
• Educates patients about their medical/behavioral health conditions and self-management.
• Collaborates with physicians and other healthcare team members on the patient’s behalf to ensure the patient receives quality and timely care and resolves any delays or issues.
• Participates in rounds or case conferences when necessary.
• Utilizes team-based care approach referring and consulting with social work, nutrition, pharmacy, rehabilitation, behavioral health, etc. resources as appropriate.
• Develops and maintains collaborative partnerships with hospital care management, post-acute providers, and other care managers to ensure seamless transitions and continuity of care.
• Avoids duplicative care management services/programs.
• Actively participates in system and regional initiatives to improve transitions of care and avoid duplicative services.
• Facilitates advanced care planning and engages in patient and family care conferences as appropriate.
• Conducts root cause analysis of extended post-acute stays, inappropriate utilization, readmissions, and tracks key data elements or metrics.
• Identifies, analyzes, and monitors industry, regulatory, technology, and market-based trends that impact ambulatory and post-acute services.
• Promotes the mission, vision, and values of Intermountain Health, and abide by service behavior standards.

Benefits

• Comprehensive benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
• PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution.
• The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates.
• Caregivers are eligible to participate in PEAK on day 1 of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level