"Alerted.org

Employment Type:

Full time

Shift:

Day Shift

Description:

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)

**SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE** :

Education:

+ Bachelor's or Master’s degree in Nursing is preferred.

Licensure:

+ Candidate must have an RN license in Idaho or Oregon and must provide licensure in their secondary state within six months of hire

Experience:

+ 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.

+ Care management experience preferred.

+ Bilingual or Multilingual communication skills (i.e., speaking, reading, writing) strongly preferred.

ESSENTIAL FUNCTIONS:

+ 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.

**Saint Alphonsus Health Alliance** is a collaborative, clinically-integrated network sponsored by Saint Alphonsus Health System. The Alliance is a network of hospitals, doctors and providers – both employed and independent - working together to see the best care principles are being delivered, so we can make unprecedented shifts towards reducing costs, improving care quality and rewarding great outcomes.

HIGHLIGHTS AND BENEFITS:

When Saint Alphonsus takes care of you, you can take better care of our patients. We foster personal and professional growth and offer opportunities that empower our colleagues to develop their careers. Our belief in work-life balance compliments the natural beauty, diverse landscapes, and outdoor recreation lifestyle that is unique to Idaho and Oregon.

+ 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.

Visit www.saintalphonsus.org/careers (https://www.saintalphonsus.org/careers/search-openings/details?j=00137722\_Speech%20Therapist%20PRN) to learn more!

MINISTRY/FACILITY INFORMATION:

Saint Alphonsus Health System is a faith-based ministry and not-for-profit health system serving Idaho, Oregon, and northern Nevada communities. The health system boasts 4 hospitals, 609 licensed beds, and 73 clinic locations. Through innovative technologies, compassionate staff, and healing environments, Saint Alphonsus' goal is to improve the health and well-being of people by emphasizing care that is patient-centered, physician-led, innovative, and community-based.

+ Top 15 Health Systems in the country by IBM Watson Health;

+ The region’s most advanced Trauma Center (Level II);

+ Commission on Cancer Accredited Program through demonstrating an uncompromising commitment to improving patient survival and quality of life.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran