Ambulatory Care Manager Castell

Job Description:

The Nurse Care Manager works collaboratively with physicians and other members of the health care team to improve the health of patients with chronic conditions or complex needs. This position educates patients and families to help them manage their health care needs. The incumbent facilitates communication, coordinates services, addresses barriers, and promotes optimal allocation of resources while balancing clinical quality and cost management.

Scope

Nurse Care Manager-MG works in the ambulatory setting. The position may work in a general care manager model to support three or more clinics within a scope narrowly aligned with designated Primary Care Clinical Program initiatives or may work in a Personalized Primary Care model (1-2 clinics) with broad scope for a defined patient population. Patient interactions may be in person, by telephone, or other electronic means.

Job Essentials

General case management

Responds to physician referrals and identifies patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or B/P, Mental Health Integration referral, complex resource needs).

Patient Evaluation

Assesses family, social, cultural characteristics.

Understands communication needs (e.g., vision, hearing).

Assesses behavioral and family risk factors.

Assesses barriers.

Screens for chronic disease (e.g. depression).

Reviews patient understanding of medication treatment.

Chronic Disease Management

Utilizes a working knowledge of established care process models and other applicable standards of care.

Provides focused patient education using established content and tools.

Uses clinician approved and appropriately documented standing orders.

Establishes individualized care plan including treatment goals in collaboration with patient and consistent with medical plan of care.

Reviews care plan and assesses progress toward treatment goals and barrier at each relevant visit.

Coordination of Care

Coordinates with care managers in other settings as appropriate.

Provides information on enabling services (e.g., transportation).

Maintains list of key community services agencies with contact information.

Provides information about recommended or available services and contacts.

Personalized Primary Care.

Support Patient in Self-Management and Behavior Change Using Motivational Interviewing and Coaching

Assesses readiness to change.

Assesses and tracks patient capacity for and confidence in self-care.

Develops self-care plan in collaboration with patient.

Provides self-monitoring tools.

Provides or connects patients with support programs.

Assesses and supports patients in adopting healthy behaviors.

Assesses and arranges treatment for mental health and substance abuse problems.

Manage Populations, Disease Registries and Preventive Care

Establishes process to monitor patient adherence to medical plan of care.

Focuses on prevention measures consistent with established guidelines and care process models

Reviews and manages quality reports related to chronic disease and prevention

Supports clinicians in achieving quality incentives.

Team Based Care

Works collaboratively with referring physician and other members of care team

Personalized Primary Care:

Completes pre-visit planning (review chart before visit, notify patient of tests needed before the visit)

Facilitates advanced care planning (Advanced Directives). Establishes a process for reminder letters and phone calls.

Supports clinicians and team to achieve personalized primary care goals.

Facilitates transitions of care (e.g., unscheduled hospital admissions, emergency department visits, skilled nursing home).

Tracks status of critical referrals.

Follows up to obtain report back from referral clinician.

In collaboration with clinician, establishes written care plan for patients transitioning from pediatrics to adult.

Provides information on health insurance resources.

Supervises and supports Health Advocates.

Attends clinic team meetings and medical home meetings to assist with process design and help resolve team issues.

Supports development of agenda for team meetings.

Reviews data summary on regular basis.

Job Specifics

• Benefits Eligible: Yes.

• Shift Details: Full time-40hrs/wk. Exempt.

• Department/Unit: Castell Care Management.

• Additional Details: Hybrid- Remote with 1-2 in person clinic (Heber Valley Clinic) visits per week.

Minimum Qualifications

Current RN license for state in which the nurse practices.

• and -

BLS certification for healthcare providers.

• and -

RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.

• and -

Three years of clinical nursing experience.

Preferred Qualifications

Experience in case management, utilization review, or discharge planning.

Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.

Physical Requirements:

Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess patient needs.

• and -

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.

• and -

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, etc.

Anticipated job posting close date:

03/18/2024

Location:

Heber Valley Clinic

Work City:

Heber City

Work State:

Utah

Scheduled Weekly Hours:

40

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

$38.83 - $57.46

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.