RN Care Manager at Intermountain Health

• 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