The University of Colorado College of Nursing is seeking a Primary Care RN Case Manager for a full-time, 1.0 FTE, benefited position. This is an outpatient care coordination role, not a bedside or inpatient nursing position. The RN Case Manager will be based at Sheridan Health Services, a Family Health Clinic located in Denver, CO (80236).
In this role, the RN Case Manager will coordinate patient care across the clinic, including connecting patients with specialty care, triaging incoming patient calls throughout the day, and helping families access available community resources. The role also includes clinical care for children and adults as part of the broader care coordination process through clinical triage, and medication administration, among other nursing duties. This RN should be team-oriented and committed to Sheridan Health Services' mission of providing care that is competent, caring, cost-effective, and delivered with a high degree of patient satisfaction.
Sheridan Health Services is a Patient-Centered Medical Home and follows a model of care that places the patient at the center, incorporating each patient's individual values and beliefs into care decisions.
Clinic Description:
Sheridan Health Services is a multi-site, nurse-managed federally qualified community health center, funded through the Health Resources and Services Administration Bureau of Primary Healthcare, and is a collaborative effort between the College of Nursing and the Sheridan School District. There are two convenient locations to serve community health needs, primarily for residents of Arapahoe, Denver, and Jefferson counties. The SHS is located in southwest Denver on the Fort Logan campus and provides services to adults and children, 65% of whom identify as Latinx, and 42% of whom are best served in another language, with Spanish being the predominant second language. Services offered include primary care across the lifespan; prenatal and postpartum, gynecology, dentistry, pharmacy, behavioral health, and outpatient substance abuse treatment.
Examples of Work Performed at All Levels:
Care Coordination (45%)
Case management and care coordination across service lines for mutual patients (i.e., Adult & Pediatric Primary Care, Maternal/Child, Behavioral Health, and Psychiatry).
Work closely with the Adult Primary Care team at FHC to assist with care coordination, navigation, and referral processing for patients with complex care needs.
Coordination of care with community partners.
Work with other SHS providers to provide comprehensive and integrated care.
Manages critical lab results and complex test results (blood work, imaging studies) through coordination with the PCP and communication with the patient to include relaying results, triage/assessment, health education, and developing a follow-up plan.
Follow up with patients identified for case management on a regular basis, helping them to assess progress toward goals and adapt the plan as needed.
Patient Care & Health Coaching (25%)
Manage independent and collaborative nursing visits focusing on optimizing health outcomes via blood pressure management and follow-up, diabetes visits, substance use disorder check-ins for medication-assisted treatment, health coaching, and nutrition counseling.
Teach self-injection for medications such as hormone replacement and diabetes medication.
Assess social determinants of health when meeting with patients to identify barriers and create individualized care plans that address specific barriers to care.
Collaborate with providers to address patient care needs over the phone.
Utilize motivational interviewing to support positive lifestyle changes to improve overall health
Quality Improvement & Community Engagement (20%)
Focuses on population-based health to improve preventive care access, immunization rates, chronic disease management measures, and health outcomes.
Ensures infrastructure for implementing, tracking, and reporting progress on quality and grant-related activities and measures.
Documents patient care using the electronic medical record system.
Takes an active role in promoting and building the integrated health team.
Participates in community outreach events.
Student/Medical Assistant Support and Training (10%)
Assists with orientation for new students, faculty, and staff to the clinic.
Precepts CU BSN students.
Serves as a resource for MAs and support staff to assist with patient care.
May exercise supervision of Medical Assistants, Patient Navigator, and/or Referral Coordinator if appropriate.
At the Entry level, duties are more limited in scope and are performed with guidance and direction from other professionals, and are performed in a training and development capacity.
At the Intermediate level, duties may be limited in scope and are performed with guidance and direction from other professionals.
At the Senior level, work is performed fully independently. In addition to the duties described above, positions at this level are responsible for:
Care Coordination:
Health Coaching:
Student/Medical Assistant Support and Training:
Assists with orientation for new students, faculty, and staff to the clinic.
Serves as a resource for MAs and support staff to assist with patient care.
Provides training to students.
Supervision and professional development of Medical Assistants if applicable.
Additional Posting Description:
At the Principal level, positions are either work leads over others or are considered subject matter experts in a particular area. In addition to the duties described above, positions at this level are responsible for:
Health Coaching:
Leads group education and health promotion initiatives. This may include developing marketing materials, recruiting patients, developing curriculum, and leading Group sessions.
Leads staff training initiatives as appropriate.
Student/Medical Assistant support and training.
Develops and leads orientation for new students, faculty, and staff to the clinic.
Serves as a resource for MAs and support staff to assist with patient care.
Heavily involved in student training. This may include the development of course activities and projects that are aligned with the course curriculum, as well as student oversight and evaluation.
Supervision and professional development of Medical Assistants.
