Ambulatory Care Manager RN

1 week ago


Richmond, Virginia, United States Bon Secours Mercy Health Full time
About the Role

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.

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 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 PCPs, 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.
  • Assist patients in advanced care planning to complete Advanced Directives.
  • Document all communications with patients and/or care teams in electronic medical records.
Requirements
  • Registered Nurse with active license in the state of patient care.
  • 2-3 years of 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.


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