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SCL Health Registered Nurse Care Manager Ambulatory in Broomfield, Colorado

You.You bring your body, mind, heart and spirit to your work as a RegisteredNurse Care Coordinator.Your compassion is tangible: patients feel it in the hand they hold.Families feel it in your prayers. Colleagues feel it in your support.You know when to move quickly. When to sit quietly. When to laugh loudly.You're great at what you do, but you want to be part of something evengreater. Because you believe that while individuals can be strong, the rightteam is invincible.Us.SCL Health Medical Group is part of SCL Health, a faith-based, nonprofithealthcare organization that focuses on person-centered care. With locationsthroughout Colorado, Montana and Wyoming, we offer a wide variety ofprimary and specialty care services.Benefits are one of the ways we encourage health for you and your family. Ourgenerous package includes medical, dental and vision coverage. But health ismore than a well-working body: it encompasses body, mind and socialwell-being. To that end, we've launched a Healthy Living program toaddress your holistic health. Healthy Living includes financial incentives,digital tools, tobacco cessation, classes, counseling and paid time off.We also offer financial wellness tools and retirement planning.We.Together we'll align mission and careers, values and workplace. We'llencourage joy and take pride in our integrity.We'll laugh at each other's jokes (even the bad ones). We'll helloand high five. We'll celebrate milestones and acknowledge the value ofspirituality in healing.We're proud of what we know, which includes how much there is to learn.Your day.As an RN Care Coordinator, you need to know how to: Perform comprehensive assessment of patients' health needs, includinghealth status and behaviors, level of function, psychosocial situation,and available support systems and determines potential needs. Establish care plans in collaboration with the primary care physician and thepatient care team. Provide health education. Identify patients at risk for proactive intervention. Pull and manipulate data to identify risk patients and present information tothe care team. Refer patients to a variety of resources including, but not limited to:nutrition, social work, rehabilitation, behavioral specialist,diabetes education, Healthy Living Workshop, etc. Contact patients who utilize ED or have been hospitalized after discharge todetermine the reason for the ED visit or hospitalization and work with patientto develop a plan to avoid those facilities. Coordinate care for complex cases or those patients seeing multiplespecialists. Maintain up-to-date and accurate documentation of patient assessment and planprovided to the patient to ensure the effective integration of information foruse by the health care team to ensure on-going and continued quality ofcare, in accordance with evidence-based practice. Analyze patient caretrends and actively seek out and collaborate with the care team to improveoverall quality and efficiency of care. Use registry data to identify problems or gaps in services and initiateintervention. Demonstrate critical thinking for problem solving and prioritization. Participate and lead patient care conferences. Manage patient panel with physician office staff to identify appropriatepatients and measure outcomes. Collaborate with physicians and office staff. Pro-actively advocate for patient care issues to ensure that overall qualityand type of care is sensitive to each specific patient/family's needs. Collaborate with payers and outside agencies to promote a patient centereddelivery concept. Participate in committees and activities related to the development ofMedical Home, Accountable Care Organization (ACO), and other insurancecarriers.Your experience.We hire people, not resumes. But we also expect excellence, which is whywe require: Associate's Degree in Nursing (ADN / ASN) Current RN license in state of practice Minimum of two (2) years of clinical experience in an outpatient settingor a minimum of two (2) year