RN Care Manager

Intermountain Health

4d•$40 - $61

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). RNs hired or promoted into this role must obtain their BSN within four (4) 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, 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.
BLS Certified

Responsibilities

Patient Identification and Assessment: 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.
Care Plan Management: 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.
Patient Support: 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.
Education and Advocacy: 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.
Multidisciplinary Collaboration: 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.
Relationship Building: 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.
Process Improvement: Actively participates in system and regional initiatives to improve transitions of care and avoid duplicative services.
Advanced Care Planning: Facilitates advanced care planning and engages in patient and family care conferences as appropriate.
Data Analysis: 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.
Mission and Values Driven: Promotes the mission, vision, and values of Intermountain Health, and abide by service behavior standards.