Ambulatory Complex Care Coordinator - RN - Center Health Equity

Join Tri Health's Center of Health Equity as a Registered Nurse Care Manager and make a meaningful impact on the lives of patients with complex health needs. Working closely with providers and interdisciplinary teams, you'll help patients navigate their healthcare journey, manage chronic conditions, overcome barriers to care, and achieve healthier outcomes. Through compassionate care coordination, education, and advocacy, you'll help advance our mission of improving health equity across the communities we serve.

• Tri Health Baldwin Corporate Offices

• Full-time position, 80-hours bi-weekly
• Shift varies
• Rotating weekend commitment
• No holiday or on-call commitments

We offer competitive shift differentials, opportunities for professional growth, and a comprehensive benefits package that may include medical, dental, vision, paid time off, retirement savings plans, and tuition reimbursement.

• Associate's Degree or diploma in Nursing (Required)
• 2 - 3 years experience Clinical Nursing Hospital nursing (Required)
• 2 - 3 years experience Clinical Nursing Care Management, Home Care (Required)
• Strong oral and written communication skills as well as strong customer service skills with phone etiquette Collaborates well with the interdisciplinary team
• Proficient computer skills
• Registered Nurse

The goal of Ambulatory Complex Care Management is to help patients reduce ED and inpatient admissions and avoid re-admissions through longitudinal care management interventions that increase patient self-management activities of chronic diseases thereby improving quality of life. The Ambulatory Complex Care Manager supports the Tri Health Primary Care Physician practices utilizing clinical nursing skills to provide care management and make transition of care calls to value based patients discharged from inpatient and emergency hospital settings.

• Collaborates with the interdisciplinary team and Primary Care Providers consistently and professionally. Communicates with their enrolled patients on a consistent bases and this is documented in the EMR in a standard way utilizing smart phrases.
• Maintains their panel of patients , completing assigned outreaches at the intervals they are due, and manages using evidence-based care such as Standards of Practice for Case Management, NCQA Standards for Care Management and program description. Utilizes both clinical and claims reports, discharge reports, predictive modeling reports to identify patients that would benefit from enrollment into the programs.
• Completes all department assigned and mandatory education and attends at least 75% of the monthly department meetings. Attends daily huddles, has their camera on when required, is available and active on web ex and e-mail throughout the working day, is responsive to calendar invitations and attends scheduled meetings on their calendar on a consistent basis.
• Ensures enrolled patients have a documented attempt for advanced care planning discussion, and this is documented in the EMR. Appropriate resources are sent to the patients and consults are made for assistance with ACP as needed. RN Care Managers provide education to patients and their families on the importance of ACP and encourage them to complete these documents and provide copies for the EMR.
• The Care Manager has attended MOLST training.
• TOC:
  Enrolls a large population of targeted patients with specific insurance contracts into the TOC program, makes scheduled outreach calls and schedules PCP follow-up appointments for these patients within specified timeframe thereby reducing re-admissions. Refers patients to CCM on a consistent basis.
• CCM:
  Enrolls patients, creates care plans, makes…