RN Complex Care Case Manager Full-Time Days

Trinity Health • Boise, ID

31d • Hybrid

About The Position

At Saint Alphonsus Health System, we are looking for people who are living out their calling. We want you to be passionate about coming to work, and challenged to achieve your potential. Living by these virtues, we pride ourselves on exceptional service and the highest quality of care. We have a great opportunity available for an RN Complex Care Manager to join our team! As an RN Care Manager with the Saint Alphonsus Health Alliance, you provide ambulatory care management and longitudinal care coordination for alternative payment model (APM) and accountable care organization (ACO) members with complex condition/illness, high utilization, and/or polypharmacy impacting health outcomes. Coordinates with physicians, staff, and other providers/facilities regarding patient care/population based management for patients in specifically defined patient populations in order to plan and implement a comprehensive, multi-disciplinary approach to manage health conditions, utilization of resources and protocols, patient self-care, implementation and evaluation of treatment plan across the care continuum (primary, secondary and continued care). Demonstrates cultural competence in working with identified ethnic populations within APM/ACO populations and utilizes multilingual support to engage and effectively communicate with patients and their support person(s), as applicable. In partnership with the primary care practice leadership team, participates in activities related to process improvement, workflow redesign, and assistance with training. In conjunction with providers, develops treatment plan, monitors care, makes recommendations for alternative levels of care, identifies cost-effective protocols and care paths and develops guidelines for care that may require coordination across systems of multiple providers/services. Complies with other duties as described (e.g., chart auditing to meet ACO compliance). Must be able to work collaboratively with the multi-disciplinary and non-clinical support team. Serves in an expanded healthcare role to support / collaborate with specialists, members of the healthcare team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Schedule: M-F; 8 hour shift; anytime from 6:30a-5:30p This is a hybrid position, working from the office and at home (once initial training period has passed)

Requirements

• Bachelor's or Master’s degree in Nursing is preferred.
• Candidate must have an RN license in Idaho or Oregon and must provide licensure in their secondary state within six months of hire
• Must possess a comprehensive knowledge of all ages seen in primary care/ambulatory care nursing, home health agency, skilled nursing facility, or hospital medical-surgical setting as normally obtained through a Bachelor’s degree in Nursing with 3 to 5 years of related nursing experience or an equivalent combination of education and experience.

Nice To Haves

• Care management experience preferred.
• Bilingual or Multilingual communication skills (i.e., speaking, reading, writing) strongly preferred.

Responsibilities

• Identifies the targeted high-risk populations from PCP referrals, risk stratification, and internal patient lists/reports. Includes patients with repeated social and/or health crises.
• Utilizes knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education in the management of patients.
• Assesses over time the healthcare, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community.
• Responsible for developing a comprehensive individualized plan of care and targeted interventions.
• Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
• Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.
• Fosters a team approach and includes patient/family as active members of the team.
• Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.
• Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Provides follow-up with patient/family when patient transitions from one setting to another.
• Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.

Benefits

• We offer market-competitive pay, generous PTO, and multiple options for comprehensive benefits that begin on day one.
• Benefits for your future include retirement planning and matching, college savings plans for your family, and multiple life insurance plans that can change as your needs develop.
• We are proud to offer Employee Assistance Programs, tuition reimbursement, and educational opportunities to help you learn and grow.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees