Ambulatory Care RN Pop Health​/Chronic Care

Ambulatory Care RN Population Health/Chronic Care Manager

Reports To: Ambulatory Care Nurse Manager

Date Issued: September 2025

Date Revised: October 2025

Job Summary: The Ambulatory Care RN Population Health/ Chronic Care Manager plays a essential role in improving patient outcomes, reducing hospital readmissions, and advancing preventive care through strategic care coordination and remote patient monitoring. This position supports key initiatives such as chronic care management and the Patient‑Centered Medical Home (PCMH), while serving as a clinical resource for safe, efficient, and responsive care delivery.

• Utilizes the nursing process to provide care management services to identify at‑risk patients by supporting patient self‑management of disease and behavior modification interventions.
• Understands PCMH concepts and supports PCMH initiatives related to care management.
• Maintains the volume of care management patients and care plans needed to meet PCMH requirements.
• Conducts patient education classes related to Diabetes Prevention, Diabetes Self‑Management, and Obesity.
• Manage and coordinate care for patients with chronic diseases and contribute to population health initiatives.
• Monitor avoidable ER visits for each MCO and reach out to patients to determine reason for ER visit. Provide patient education on best way to utilize medical services.
• Assist coordination of post‑discharge follow‑up appointments and needed medication and supplies.
• Coach patients and family in follow‑up to chronic health conditions and self‑management strategies presented during hospitalization and planned clinic/health‑care provider visits.
• Assist the Population Health Manager in identifying and mitigating gaps in care.
• Educate nonadherent patients on the importance of closing care gaps and monitor patients for compliance.
• Build and maintain positive working relationships with the patients, family members, providers, case managers and other health agency representatives.
• Continuously expand knowledge and understanding of community resources, services, and programs.
• Provides triage service in person or over the telephone.
• Provides health teaching and counseling to patients and families. This may include communication test results, medication changes, etc.
• Provides direct nursing care to patients, including performing assessments, nursing procedures (including injections), and assistance with procedures.
• Offer medication reconciliation and adherence counseling while assessing patient knowledge and addressing barriers to adherence and self‑care.
• Assesses patient requests for same‑day services and works with Providers and Center Manager to ensure that patient needs are addressed appropriately.
• Expedites patients flow through the implementation of standing orders or policies for medication refills, referrals, and immunizations. Ensures that clinical medical assistants are familiar with standing order protocols and follow them appropriately.
• Participates in the immunizations process, including inventory and record keeping. Ensures that vaccines are stored properly. Oversee immunization administration process and educate staff regarding proper technique and current recommendations. Has knowledge of the Vaccines For Children program and assists with compliance.
• Oversees laboratory services, including review of quality control, oversight of inventory and record keeping. Ensures that supplies are stored properly. Supervises specimen collection process and in‑house testing and educates staff regarding proper technique and current recommendations.
• Participates in the maintenance of medication and medical supply inventory, including monthly expiration process.
• Provides clinical training to medical assistants and supervises competency evaluations as directed by the Ambulatory Care Nurse Manager.
• Demonstrates proficiency in the use of the EMR and serves as a clinical resource.
• Completes all other duties as assigned.

• Participates in team/staff meetings; attends in‑service meetings and applicable workshops.
• Performs other duties as assigned.

Core Values: Quality Respect Teamwork Equity Integrity Passion Love