Job Description:
Responsible for assessment, care coordination, discharge planning, and post-acute referrals for patients with complex medical and/or social determinants of health needs in the acute hospital setting.
As an RN Care Manager, you need to know how to:- Perform comprehensive assessment of patients health needs, including health status and behaviors, level of function, psychosocial situation, and available support systems and determines potential needs.
- Establish care plans in collaboration with the primary care physician and the patient care team.
- Provide health education.
- Identify patients at risk for proactive intervention.
- Pull and manipulate data to identify risk patients and present information to the care team.
- Refer patients to a variety of resources including, but not limited to: nutrition, social work, rehabilitation, behavioral specialist, diabetes education, Healthy Living Workshop, etc.
- Contact patients who utilize ED or have been hospitalized after discharge to determine the reason for the ED visit or hospitalization and work with patient to develop a plan to avoid those facilities.
- Coordinate care for complex cases or those patients seeing multiple specialists.
- Maintain up-to-date and accurate documentation of patient assessment and plan provided to the patient to ensure the effective integration of information for use by the health care team to ensure on-going and continued quality of care, in accordance with evidence-based practice. Analyze patient care trends and actively seek out and collaborate with the care team to improve overall quality and efficiency of care.
- Use registry data to identify problems or gaps in services and initiate intervention.
- Demonstrate critical thinking for problem solving and prioritization.
- Participate and lead patient care conferences.
- Manage patient panel with physician office staff to identify appropriate patients and measure outcomes.
- Collaborate with physicians and office staff.
- Pro-actively advocate for patient care issues to ensure that overall quality and type of care is sensitive to each specific patient/family's needs.
- Collaborate with payers and outside agencies to promote a patient centered delivery concept.
- Participate in committees and activities related to the development of Medical Home, Accountable Care Organization (ACO), and other insurance carriers.
Minimum Qualifications- Bachelors Degree (BS/BA/BSN)
- Current RN license in state of practice
- Minimum of two (2) years of clinical experience in an outpatient setting
- or a minimum of two (2) years of experience coaching individuals with complex and/or chronic conditions
Preferred- Prior experience in care coordination in a community setting or primary care practice
- Program development, operations management, and/or supervisory experience
Physical Requirements:
Location:
Platte Valley Hospital
Work City:
Brighton
Work State:
Colorado
Scheduled Weekly Hours:
40
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
$39.99 - $59.18
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.
Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers, and for our Colorado, Montana, and Kansas based caregivers; and our commitment to diversity, equity, and inclusion.
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.