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CommonSpirit Health RN Care Coordinator in Phoenix, Arizona


Arizona Care Network is a Dignity Health joint venture. We access our employee benefits and Human Resources systems through DHMSO, a division of Dignity Health.

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 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.



Minimum 2 years experience as a Case Manager in a hospital, nursing home, medical group, or health plan setting.


Bachelor Degree in Nursing or equivalent experience ; Current Registered Nurse License in Arizona.

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Equal Opportunity

Dignity Health is an Equal Opportunity/ Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please

Dignity Health will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c).

External hires must pass a post offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request . We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA).

Dignity Health participates in E-verify.

Job ID 2020-134008

Employment Type Full Time

Department Case Management

Hours / Pay Period 80

Facility Dignity Health Management Services Organization

Shift Day

Standard Hours Monday - Friday (8:00 AM - 5:00 PM)

Work Schedule 8 Hour

Location AZ-Phoenix