RN House Calls 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, and develops and implements patient-centered care plans with shared goals and appropriate interventions. The Care Manager collaborates with patients, families and caregivers, healthcare providers, payers, community-based providers, and other involved parties to provide efficient, effective, patient-centered care management. Work takes place across transitions of care, clinics, communities, and post-acute care environments, supporting proactive care for at-risk patients.

This full-time position requires travel throughout the service area, from Santaquin to Park City. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., for 40 scheduled hours per week. The position is based at Intermountain Health Utah Valley Hospital in Provo, Utah. The hourly pay range is $41.20–$62.17, depending on experience.

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 variation in care.
• Proficiency in basic computer skills and Microsoft Office software.
• For home or community visits, current BLS certification, a current driver’s license, current auto insurance, an acceptable driving record, and reliable transportation are required.
• Ability to meet the described physical demands, including seeing and reading information, communicating and hearing effectively, manual dexterity, lifting and transferring patients or supplies, walking, pushing or pulling equipment, and, where applicable, driving.

Nice To Haves

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

Responsibilities

• Identify patients for proactive interventions using screening criteria, medical record review, payer models, medical risk scores, or referrals.
• Assess patients’ medical, functional, and social conditions to develop individualized care plans and connect patients with community resources; assess patients per NCQA standards as appropriate.
• Develop, maintain, and monitor patient care plans consistent with NCQA and department policies, supporting adherence to medical plans and preventive measures.
• Coordinate internal and external services for social determinants of health needs and community care; evaluate care-plan effectiveness and outcomes, and modify plans or interventions as appropriate.
• Support patient self-management and behavior change through motivational interviewing and coaching; assess readiness and capacity for change and confidence in self-care.
• Educate healthcare team members about case management processes and appropriate referrals, and advocate for patient rights.
• Educate patients about medical and behavioral health conditions and self-management.
• Collaborate with physicians and other healthcare team members to ensure timely, quality care and resolve delays or issues; participate in rounds or case conferences as needed.
• Use a team-based care approach, referring and consulting 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 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 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 abide by service behavior standards.

Benefits

• Benefits eligible; the employer offers a comprehensive benefits package intended to support caregivers’ well-being across health, security, connection, and engagement. Specific benefit offerings are not listed in the posting.

What This Job Offers

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