RN Ambulatory Care Manager

Delivers comprehensive ambulatory care management services to identified patients. Leverages clinical expertise to conduct care management screenings, assessments, and evaluations. Develops and implements patient-centered care plans with shared goals and appropriate interventions. Collaborates with patients, families/caregivers, healthcare providers, payers, community-based providers, and other involved parties to ensure efficient, effective, and patient-centered care management services across various settings, including transitions of care, clinics, communities, and post-acute care environments.

Essential Functions

• 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.
• 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.
• 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.
• Educates 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.
• 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.
• 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.
• Actively participates in system and regional initiatives to improve transitions of care and avoid duplicative services.
• Facilitates advanced care planning and engages in patient and family care conferences as appropriate.
• 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.
• Promotes the mission, vision, and values of Intermountain Health, and abides by service behavior standards.

Requirements

• 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.

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 to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies.
• Frequent interactions with patient care providers, patients, and visitors requiring verbal communication, hearing, and understanding 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, including 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, including 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, including 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.

Schedule

Full time, Monday-Friday, Days. No weekends.

Pay

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

Benefits

Comprehensive benefits package that covers a wide range of programs to foster a sustainable culture of wellness, including mind, body, and spirit. Learn More About Our Comprehensive Benefits Package Here.

Location

Nevada Central Office, Las Vegas, Nevada. Scheduled weekly hours: 40.