Registered Nurse Community Care Manager House Calls (imh)

Job Description

Job Description:

Provides longitudinal care management services for identified patients. Utilizes clinical expertise to perform care management screening, assessment/evaluation, and develop and implement a patient-centered plan of care with shared goals and appropriate interventions. Provides extraordinary and value-based care management. Works collaboratively with patients, family caregivers, significant others, healthcare providers, payers, community-based providers, and other involved parties to provide effective, efficient, and patient-centered care management services.

Job Essentials

Understands, practices, and promotes the philosophy and guiding principles of integrated care management. Develops relationships and collaborates with case/care management staff in episodic settings and across the continuum to promote process integration, seamless transitions from one case/care management program to another, continuity of care, and avoid duplicative care management services/process.

Patient Identification: Screens, identifies, and prioritizes patients appropriate for the program. Assigns patients with identified needs to a primary planner. An appropriate primary planner is assigned based on the individual's needs.

Assessment/Evaluation: Typically assigned as the primary planner for clinically complex patients. Meets with the patient in a timely manner and conducts an initial care management assessment/evaluation.

Care Planning: Develops a patient-centered plan of care, involving the patient/family, caregiver/significant others in the process. Problems and strengths are defined, and shared goals and desired outcomes are established.
Intervention: Collaborates, educates, communicates, and networks with healthcare providers across the continuum to ensure the patient's care planning needs are met.

Intervention: Advocates on behalf of the patient, communicating and collaborating with healthcare providers, payers, physicians, and community-based services, where appropriate, to establish an appropriate and integrated care plan for each patient.

Intervention: Provides patient/family caregiver self-management education, referrals, and support.

Intervention: Promotes mental health integration by collaboration with mental health/behavioral health providers.

Intervention: Facilitates transitions of care from one healthcare setting to another. Actively participates in system and regional process improvement initiatives to improve transitions of care.

Intervention: Identifies and assists patients/members with palliative care and end-of-life care planning needs.

Re-assessment/Re-evaluation: Evaluates the effectiveness of the patient's plan of care and outcomes and modifies the plan of care or specific interventions, as appropriate.

Leadership: Functions as the team leader, ensuring effective day-to-day operations and problem solving, for the Community Case Management team. Promptly escalates concerns to appropriate chain of command.

Leadership: Effectively and efficiently leads interdisciplinary care conferences, using collaborative practice models that promote interdisciplinary care planning and teamwork.

Completes timely and accurate documentation in the medical record using knowledge of documentation standards for the department to facilitate communication with team members. Documentation is done in compliance with all clinical guidelines and billing/reimbursement standards.

Organizes and prioritizes daily work by assessing new, current, and discharging patient needs in area(s) of responsibility.
Ensures that productivity standards and expectations are met.
 

Minimum Qualifications:

• Current RN license in state of practice.
• Current Driver's License in the state of practice.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
• Basic Life Support for Healthcare Providers.
• Three years of clinical nursing experience.
• Three years of experience working as a case/care manager in a healthcare setting.
• Record as a safe driver. Will be asked to provide a copy of their Motor Vehicle Record (MVR) from the Dept. of Motor Vehicles upon hire.
• Auto liability insurance with at least the state's required minimum limits.

Preferred Qualifications:

• Bachelor's degree in Nursing (BSN) from an accredited institution. Degree will be verified.
• Case Management Certification.
• Team leader experience.
• Experience working with third party payers.
• Knowledge of community- based health services and resources.
• Excellent written and verbal communication skills.
• Independent worker, who is self-motivated, has a positive attitude, and can be flexible in a rapidly changing healthcare environment.
• Auto liability coverage higher than the State's required minimum (at least $100,000/$300,000 is encouraged).

Physical Requirements:

Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies.
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Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.
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Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, and driving a vehicle.
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Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items.
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Frequently walks and assists with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling portable equipment, including heavy items. Often required to navigate crowded and busy rooms (e.g., full of furniture, equipment, power cords on the floor). Need to ascend and descend stairs or uneven surface to access patients.
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Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Location:

Intermountain Health McKay-Dee Hospital

Work City:

Ogden

Work State:

Utah

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience. 

$43.98 - $63.79

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 package here.

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.