RN Transitional Care Manager

  • Brighton
  • Intermountain Healthcare
Job Description:

Responsible for specialty care management for assigned clinics/geographical areas and other appropriate referrals within the Intermountain system. Assess, plan, educate, and advocate for patient's health needs by collaborating with the patient/family, physician(s), other health care providers, national organizations, and community resources. Collaboratively develop and implement a plan of care that meets the patient's healthcare goals, promotes shared-decision making, optimizes allocation of resources, and facilitates patient engagement and self-care management across the care continuum.


Identify patients for proactive interventions using payor models and medical risk scores.

Lead pre- and post-hospital transition of high-risk patients, developing a transitional care plan in collaboration with patient/family and care team.

Conduct post-acute phone calls, providing care coordination and health coaching, including patient/caregiver/family education in disease management, while addressing the social determinants of health and other barriers to optimal health outcomes.

Facilitate hand-offs to Ambulatory Care Coordinators when appropriate.

Perform tasks identified as part of an episodic payment model, value-based purchasing program, or other identified patient population for transitional care management of patients across the health-care continuum.

Develop and maintain proactive, collaborative partnerships with the post-acute provider partner network to manage patient length of stay and optimize recovery in the most appropriate level of care.

Collaborate with multiple stakeholders for the purposes of education, risk stratification, identification of barriers to successful post-acute care planning.

Conduct root cause analysis of all extended post-acute stays and re-hospitalizations for presentation and analysis at internal operations committee meetings. Facilitate data collection and tracking of key data elements or metrics as defined for each episode model. Work with finance associates to synthesize and understand patient trends and outcomes.

Minimum Qualifications:

Bachelor’s degree in nursing (BSN) from an accredited nursing program.

Current valid state RN license.

Minimum of five (5) years of nursing experience in either an acute care, post-acute care, or ambulatory care setting.

Demonstrated experience in data collection, tracking, and reporting.

Demonstrated electronic EHR experience.


Master’s degree in a work-related discipline/field from an accredited college or university.

Current Care Management certification.

At least three (3) years of care management experience, either hospital- or community-based.

Previous experience in an episodic payment model program.

Physical Requirements:

Physical Requirements

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

Anticipated job posting close date:


Good Samaritan Medical Center, Platte Valley Medical Center

Work City:


Work State:


Scheduled Weekly Hours:


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

$32.84 - $58.35

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.