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Ambulatory Care Manager RN
2 months ago
Bon Secours Mercy Health is seeking a highly skilled Ambulatory Care Manager RN to join our team. As a key member of our healthcare organization, you will play a vital role in providing clinical care management services to eligible patients, coordinating care to achieve desired health outcomes, and improving self-care abilities while reducing unnecessary healthcare costs.
Key Responsibilities- Perform standardized comprehensive needs assessments to identify and address barriers to care, aligning patients with available benefits and resources.
- Collaborate with patients, providers, and care teams to develop and implement plans of care that ensure medically appropriate, cost-effective care.
- Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management of their chronic conditions, aiming to improve symptom management and interrupt negative disease trajectories.
- Maintain a caseload of patients according to department policies and identify, enroll, and manage patients in programs for Transitions of Care, Complex Case Management, and Chronic Disease Management.
- Develop and implement care plans to maximize healthcare outcomes and facilitate wellness, with periodic review and update according to department protocols.
- Perform medication reviews and teach-backs to ensure patient understanding and adherence to medical regimens.
- Collaborate with Primary Care Physicians, Specialists, and Hospitalists to effectively implement patient-centered care plans.
- Perform patient outreach according to established protocols and document in electronic medical records.
- Identify, execute, and track needed referrals to care and community resources.
- Provide resource management to improve care, patient experience, and reduce unnecessary costs and utilization: right care, right place, right time.
- Assist patients in advanced care planning to complete Advanced Directives.
- Document all communications with patients and/or care teams in electronic medical records.
- Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served on their assigned unit.
- Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to their age, specific needs, and to provide the care needed as described in departmental policies and procedures.
- Neonates (0-4 weeks), Infants (1-12 months), Pediatrics (1-12 years), Adults (18-64 years), and Geriatrics (65 years and older).
- Education Qualifications: Associate's Degree in Nursing, Preferred Education: Bachelor's Degree in Nursing (BSN).
- Licensure/Certification Required: Registered Nurse with active License in State of Patient Care, Licensure/Certification Preferred: Case Management certification.
- Minimum Qualifications: 2-3 years acute care, home health, or case management experience.
- Excellent interpersonal communication and negotiation skills, Strong analytical, data management, and computer skills.
- Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting.
