RN Ambulatory Care Manager

Patient Identification and Assessment

Leverages clinical expertise to identify patients for proactive interventions using specific screening criteria, medical record review, payor models, medical risk scores, or referrals. Conducts assessments of 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

Edits healthcare team members about case management processes, appropriate referrals, and advocates 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 abides by service behavior standards.

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.
• MVR Verification.
• 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.