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HonorHealth is one of Arizona's largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 14,000 team members, 3,700 affiliated providers and hundreds of volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.
Responsibilities
Job Summary
This position oversees the coordination of care for the ICP high risk and complex cases. Responsible for ensuring all health care team members (Hospitalists, Specialists, Transitional Care Managers (TCM), Care Coordinators (CC), Primary Care Physician (PCP), families, etc.) understand complex needs of high-risk cases using highly effective communication and clinical skills. This position will be key in maintaining an updated plan of care with the CC's. Complex Care Manager - RN is an integral member of the care management team, working with patients and their families to assure a coordination of highly complex needs. This position works collaboratively with the Chief Medical Officer, providers, hospital based specialists, Care Coordinators and other health care professionals/agencies to ensure outpatient care is coordinated across the health care continuum.
- Responsible for ensuring all health care team members (Hospitalists, Specialists, Transitional Care Managers (TCM), Care Coordinators (CC), Primary Care Physician (PCP), families, etc.) understand complex needs of ICP's high-risk cases using highly effective communication and clinical skills. This position will be key in completing a complex care plan and maintaining an updated plan of care in collaboration with the CC's. Conducts in home visits with the care coordinator for identified complex care patients. Under the direction of the Director of Care Coordination, will be working with patients and their families to assure a coordination of highly complex needs.
- Contributes to the education of patients and families on advanced directives, community resources, palliative care, disease process, signs of worsening symptoms and other supportive interventions. This position works collaboratively with the Chief Medical Officer, providers, hospital based specialists, Care Coordinators and other health care professionals/agencies to ensure complex outpatient care is coordinated across the health care continuum.
- Assesses complex care cases for social determinants of health (SDoH) barriers. Provides resources and documents interventions aligned with controlling SDoH needs. Coordinate other services such as mobile in-home services, placement coordination, advanced care planning, family conferences. Identify complex resource services such as homeless shelter, drug rehabilitation, seriously mentally ill, etc.
- Serves as a resource to others including staff, providers, leadership, patients and families. Facilitates inter/intra departmental collaboration, communication and promotes problem solving. Understand and follow all local, state, and national regulatory standards for care management.
- Performs other duties as assigned.
Qualifications
Education
Associate's Degree from an accredited NLN /CCNE institution in nursing Required
Experience
2 years experience in acute or outpatient health care settings Required
Licenses and Certifications
Registered Nurse (RN) State And/Or Compact State Licensure Required
Basic Life Support (BLS) Required