RN House Calls Care Manager

Intermountain Healthcare Inc.; United States; On-site; USD 57,000 - 86,000; Full time

Benefits offered by this job

Benefits Eligible

Full-time

Weekday shift

Job summary

Intermountain Health is seeking an RN Ambulatory Care Manager I to deliver proactive ambulatory care management across clinics and post-acute settings. You will assess patients, develop individualized care plans, and coordinate with families, providers, and community resources to improve outcomes.

The role requires a BSN, chronic disease management experience, and the ability to travel across the service area.

Qualifications

• Current RN license in state of practice.
• BSN required; must obtain BSN within four years of hire.
• Demonstrated clinical nursing experience in chronic disease management.
• Familiarity with chronic disease terminology and processes.
• Proficiency in basic computer skills and Microsoft Office.
• Caregivers whose duties require home or community visits must maintain BLS certification, a valid driver’s license, current auto insurance and reliable transportation.

Responsibilities

• Identify patients for proactive interventions and assess medical, functional, and social needs to develop individualized care plans.
• Develop, maintain, and monitor patient care plans aligned with NCQA standards and coordinate services.
• Support patient self-management and behavior change using motivational interviewing and coaching techniques.
• Educate healthcare team members about case management processes and advocate for patient rights; educate patients on conditions and self-management.
• Collaborate with physicians and other team members to ensure timely, quality care and coordinate with social work, nutrition, pharmacy, and rehabilitation resources.
• Participate in rounds or case conferences; drive system and regional initiatives to improve transitions of care.

Skills

RN license

BSN

Chronic disease management

Medical terminology familiarity

Basic computer skills

BLS certification

Driver’s license & reliable transport

Education

BSN from accredited institution

Care Management Certification

Job description

Job Description

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.

Travel Requirements

This RN Care Manager position requires travel throughout the service area, from Santaquin to Park City.

Benefits and Eligibility

• Benefits Eligible: Yes
• FTE: Full time
• Shift: Monday - Friday, 8:00am- 5:00pm

Essential Functions

• 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.

Minimum Qualifications

• 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.

Preferred Qualifications

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

Physical Requirements

Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies. Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations. Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc. Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items. Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling gurneys and portable equipment, including heavy items. Often required to navigate crowded and busy rooms (full of equipment, power cords on the floor, etc.) May be expected to stand in a stationary position for an extended period of time. For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Location, Hours and Salary

Location: Intermountain Health Utah Valley Hospital Work City: Provo Work State: Utah

Scheduled Weekly Hours: 40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $41.20 - $62.17

Benefits

• We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous 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.

Legal and Compliance Statements

By applying for a position with Intermountain, I acknowledge that I will comply with all applicable Intermountain policies and expectations. I further acknowledge that outside employment or activities may not interfere with job responsibilities or create a conflict of interest with Intermountain. Actual or reasonably perceived conflicts may be grounds for disqualification from consideration or, if hired, corrective action up to and including termination of employment.

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

All positions subject to close without notice.

Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.

Join our world‑class team and embark on a career filled with opportunities, strength, innovation, and fulfillment. Intermountain Health’s 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.

The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor.

Thanks for your interest in continuing your career with our team!