**Job Description:** Responsible for assessment, care coordination, discharge planning, and post-acute referrals for patients with complex medical and/or social determinants of health needs in the acute hospital setting. **Job Description** + Coordinates the care and services for patients identified as needing assistance or meeting Care Management criteria. + Collects in-depth information about a patient’s medical, functional, and social condition, to identify individual needs in order to develop a plan to meet those needs. + Works with patients and family/caregivers to determine specific goals and actions based on assessment. + Coordinates discharge planning. + Executes specific interventions to meet established goals. + Organizes, integrates and coordinates the necessary resources to accomplish the goals and plan. + Assists the care team in developing a plan of care which includes but is not limited to assuring appropriateness of services and care setting, assuring individualized support and education, determining the need for continued services, planning for discharge, and identifying and connecting patients/families with available community resources if needed. + Collaborates with Physicians and other members of the health care team on the patient’s behalf. + Maintains up-to-date and accurate documentation of patient assessment and plan of care to ensure effective integration of information for use by the health care team to ensure on-going and continued quality of care. + Identifies appropriate admission and continued stay issues. + Enhances the quality of patient care through effective and efficient use of resources. + Helps to identify strategies for reducing length of stay and appropriate utilization of services. + Utilizes criteria including clinical pathway data and implements strategies to resolve controllable variances. + Attends, facilitates and participates in interdisciplinary rounds and case conferences. + Advocates for patient rights. + Promotes mission, vision, and values of Intermountain Health, and abides by service behavior standards. + May be required to work days, evenings, weekends, and holidays. + Performs other duties as assigned. **Minimum Qualifications** + Graduation from an accredited School of Nursing is required. + BSN or ASN/ADN degree with BSN degree required within 4 years of hire. + 3 years Registered Nurse experience. **Preferred:** + BSN at time of hire is preferred. + 3 years Care Manager experience in an acute or ambulatory setting is preferred. **Physical Requirements:** • Ongoing need for employee to see and read information, documents, monitors, identify equipment and supplies, and be able to assess customer needs. • Frequent interactions with providers, colleagues, customers, patients/clients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately. • Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc. **Location:** St. Marys Regional Hospital **Work City:** Grand Junction **Work State:** Colorado **Scheduled Weekly Hours:** 40 The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $36.35 - $54.53 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 (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/) , and for our Colorado, Montana, and Kansas based caregivers (http://www.sclhealthbenefits.org) ; and our commitment to diversity, equity, and inclusion (https://intermountainhealthcare.org/careers/working-for-intermountain/diversity/) . 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. All positions subject to close without notice.