Dignity Health

RN Care Coordinator

Job ID
Employment Type
Full Time
Case Management - Population Health
Hours / Pay Period
Dignity Health Management Services Organization
Standard Hours
Mon-Fri (8-5 PM)


The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.


Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.


 The Arizona Care Network (ACN) is a clinically integrated physician network (CIN) established as a result of a Dignity Health and Tenet Health physician collaboration.  The Embedded Care Specialist is an employee of  Dignity Health Management Services Organization.


The Embedded Care Registered Nurse (ECRN) is an individual with significant experience and demonstrated ability to engage providers and care teams in collaborative care, generation of better clinical outcomes, driving higher patient satisfaction with service delivery, and efforts to improve the cost-efficiency and value of service delivery.


In this role the ECRN supports the community clinical care teams in such a manner that the ECRN becomes an integral part of the local care team (either in-person or virtually) providing care coordination under the supervision of the patient’s personal clinician.


The ECRN also represents to the community clinical care teams ACN’s significant Population Health Management (PHM) capabilities in order to allow for the expansion and intensification of PHM activities within all care locations across the network, to include ambulatory and inpatient facilities. In this role the ECRN will provide actionable information that will allow each care team to take advantage of the risk-segmentation, risk-stratification, care gap analysis, clinical and financial benchmarking, and specialized Care programs and campaigns made available by ACN to all its collaborating clinical sites.


 The ECRN works under the direct supervision of the ACN  Manager Embedded Care with the ACN Chief Medical Officer having direct oversight of the clinical integrity. The RN will be working in the community, hospitals, provider offices, skilled nursing facilities, the ACN Command Center and other embedment opportunities to support patient care as available.


Plans and coordinates all phases of skilled nursing care coordination using a problem solving process that includes assessment, problem identification, goal definition, plan development, evaluation to achieve optimum patient outcomes.  This position requires a successful track record of interaction with physicians, facility nursing staff, patients and their families, as well as all aspects of patient care management including referral development, assessment of patient clinical needs, and coordination of the interdisciplinary plan of care.




  • Concurrently reviews patient’s records to collect data to carefully understand the needs of the patient by scrutinizing their background history, understanding their current needs, and arranging for their wellbeing.
  • Using industry guidelines, assesses appropriateness of admission, level of care, and length of stay.
  • Coordinates with other disciplines to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements.   Anticipates and identifies variances in the care process related to those identified needs.
  • Assists in development, implementation and revision of individual treatment plans; assures that services provided are specified in the Treatment Plan and monitors progress toward treatment goals, including documentation of daily improvement in patient’s condition or otherwise notes lack of improvement for reassessment of appropriateness of treatment plan.
  • Communicates with the nursing home physicians, regularly, to evaluate the status of each patient. Collaborates with other team members to ensure appropriate interventions are implemented.  These communications will be needed as frequently as is need to ensure care is appropriate according to patient status.
  • Coordinates with other disciplines to facilitate the patient receiving the required care at the expected time including plan of care to reduce incidence or re-admission to acute care setting, including physical, occupational and rehabilitative therapy.
  • Coordinates transfers to a lower level of care, home health referrals, and durable medical equipment delivery to facilitate discharge from skilled nursing facility.
  • Measures effectiveness and outcomes of the care plan and collaborates with the health care team for quality improvement.
  • Interacts with patient and family providing transition plan for treatment goals and post-discharge needs.
  • Assesses and makes referrals to appropriate community resources to facilitate patient progression toward expected goals/outcomes.
  • Has a working knowledge of the financial aspects related to a variety of payer sources.
  • Reports weekly to the Director of Embedded Care or Medical Director for Quality and Utilization regarding patient status and identifies any potential risk management.
  • Maintains case files and reports.





  1. A) EXPERIENCE: Minimum 2 years experience as a Case Manager in a hospital, nursing home, medical group, or health plan setting.
  2. B) EDUCATION AND TRAINING: Bachelor Degree in Nursing or equivalent experience ; Current Registered Nurse License in Arizona.


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