RN House Calls Care Manager

Intermountain Health; Utah; In loco; USD 75.000 - 110.000; Tempo pieno

Descrizione del lavoro

Intermountain Healthcare Inc. in Utah seeks an RN Ambulatory Care Manager I to deliver comprehensive ambulatory care management. You will conduct screenings, assessments, and develop patient-centered care plans with families and providers across clinics and post-acute settings.

Travel across the service area is required. You will support transitions of care, educate teams, and monitor outcomes using NCQA standards to improve quality and reduce readmissions. Regular daytime hours schedule.

Competenze

• Current RN license in state of practice.
• BSN from an accredited institution; BSN must be obtained within four years of hire/promotion.
• Demonstrated clinical nursing experience in chronic disease management.
• Familiarity with chronic disease terminology and processes.
• Proficiency in basic computer skills and Microsoft Office software.
• Caregivers with home/community visits must maintain BLS, valid driver's license, current auto insurance, acceptable driving record and reliable transportation.

Mansioni

• Identify patients for proactive interventions using screening criteria and risk scores.
• Develop and monitor patient care plans aligned with NCQA standards.
• Coordinate internal and external services for Social Determinants of Health needs.
• Provide patient education and advocate for patient rights.
• Collaborate with physicians and care teams to ensure timely care and resolve delays.
• Participate in rounds/case conferences and support transitions of care.

Conoscenze

Motivational interviewing

Basic computer skills

Team collaboration

Formazione

BSN

Strumenti

Microsoft Office

Descrizione del lavoro

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.

Job Specifics

Benefits Eligible: Yes
FTE: Full time
Shift: Monday - Friday, 8:00am - 5:00pm
This RN Care Manager position requires travel throughout the service area, from Santaquin to Park City.

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 in