Registered Nurse Ambulatory Care Manager; RN - Population Health

Registered Nurse Ambulatory Care Manager (RN) - Population Health

Registered Nurse (RN) who will provide clinical care management services to identified eligible patients; coordinating care to obtain desired health outcomes, improve self‑care abilities, and decrease unnecessary cost of care. Conduct standardized comprehensive needs assessment, identify and address barriers to care, align patients with available benefits and resources. Collaborate with patient, provider and care team to develop and implement plan of care to ensure medically appropriate cost‑effective care.

This position is primarily remote / work from home. Hire must be able to go onsite up to 20% to support the Hampton Roads, VA market.

• Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self‑management of their chronic conditions with the goal of improved symptom management and interruption of a negative disease trajectory.
• Maintain a caseload of patients according to department policies.
• Identify, enroll, and manage patients in program for Transitions of Care/Complex Case Management/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 review and teach‑back to ensure patient understanding and ability to adhere to medical regimen.
• Collaborate with PCPs, specialists, and hospitalists to effectively implement a patient-centered care plan.
• Perform patient outreach according to established protocols and document in electronic medical record.
• Identify, execute, and track needed referrals to care and community resources.
• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
• Assist patient in advanced care planning to complete Advanced Directives.
• Document all communications with patient and/or care team in electronic medical record.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

• Associate’s Degree (required) – Specialty/Major:
  Nursing
• Bachelor’s Degree (preferred) – Specialty/Major:
  Nursing (BSN)

• Registered Nurse with active License in State of Patient Care (required)
• Case Management certification (CCM) (preferred)

• 2–3 years acute care, home health or case management experience (required)

• Excellent interpersonal communication and negotiation skills; strong analytical, data management and computer skills (required)
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting (preferred)

• Neonates (0‑4 weeks)
• Infant (1‑12 months)
• Pediatrics (1‑12 years)
• Adolescents (13‑17 years)
• Adults (18‑64 years)
• Geriatrics (65 years and older)

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurance, mental health resources and discounts
• Paid time off, parental and FMLA leave, short‑ and long‑term disability, backup care for children and elders
• Tuition assistance, professional development and continuing education support

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at