Registered Nurse Transitions and Triage Care Management

Job Description

Full Time Position

The RN Transition and Triage Care Manager offers comprehensive, time-limited services to patients and their families, ensuring continuity of care as they move across healthcare settings and clinicians. This role aims to prevent health complications, connect patients to resources, and guide them to the appropriate level of care. Utilizing clinical expertise, technology, and evidence-based practices, the manager assesses, plans, implements, and evaluates patient care through telephone or digital communication methods.

Effective collaboration with patients, families, healthcare providers, payers, community-based providers, and other involved parties is essential to deliver efficient, effective, and patient-centered care management services. The manager operates in various settings, including triage, transitions of care, clinics, communities, and post-acute care environments.

• Patient Identification and Assessment:
  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, care recommendations, or referrals as appropriate.
• Care Plan Management:
  Coordinates with internal and external services for social determinants of health (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.
• Acute Symptom Triage:
  Conducts remote nursing assessments:
  Utilizes critical thinking skills to assess patient symptoms, medical history, and concerns, applying evidence-based protocols to determine appropriate care recommendations.
• Patient Support:
  Supports patient self-management and behavior change through health coaching, care navigation, care coordination, and education of identified patient/caregiver/family to identify and address barriers to optimal health outcomes.
• Education and Advocacy:
  Educates healthcare team members about transitions and triage processes, appropriate referrals, and advocate 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 patient receives quality and timely care and resolve 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.
• Data Analysis:
  Conducts root cause analysis of extended post-acute stays, inappropriate utilization, readmissions, and track 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.

• Assessment
• Care Planning
• Transitions of Care
• Motivational Interviewing
• Critical Thinking
• Time Management
• Customer Service
• Patient Education
• Communication
• Prioritization

• 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 date.
• Demonstrated clinical nursing experience in chronic disease management, and familiarity with chronic disease terminology and processes.
• Demonstrated…