Registered Nurse Ambulatory Care Manager; RN — Population Health

Summary

As a Registered Nurse (RN), the Ambulatory Care Manager provides clinical care management services to identified eligible patients. Responsibilities include coordinating care to achieve desired health outcomes, improving self‑care abilities, and reducing unnecessary cost of care. The role involves performing standardized comprehensive needs assessments, identifying and addressing barriers to care, aligning patients with available benefits and resources, and collaborating with patients, providers, and care teams to develop and implement a medically appropriate, cost‑effective plan of care.

• Utilize Motivational Interviewing techniques to activate patients in self‑management of chronic conditions.
• Maintain a caseload of patients according to department policies.
• 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 health outcomes and facilitate wellness, with periodic review and updates per department protocols.
• Perform medication reviews and teach‑back to ensure patient understanding and adherence.
• Collaborate with PCPs, specialists, and hospitalists to implement a patient‑centered care plan.
• Conduct patient outreach according to established protocols and document in the electronic medical record.
• Identify, execute, and track necessary referrals to care and community resources.
• Provide resource management to improve care, patient experience, and reduce unnecessary cost and utilization.
• Assist patients in advanced care planning to complete advanced directives.

• Associate’s Degree in Nursing (required).
• Bachelor’s Degree in Nursing (preferred).

• RN compact license or Multi‑State license (required).
• Case Management certification (preferred).

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 health of a distinct patient population in ambulatory or community settings (preferred).

The following must be included in all position descriptions that involve direct or indirect patient care. This is a JCAHO requirement. Select the age of the patient population served.

• Neonates (0‑4 weeks)
• Infants (1‑12 months)
• Pediatrics (1‑12 years)
• Adolescents (13‑17 years)
• Adults (18‑64 years)

• Competitive pay, incentives, referral bonuses, and 403(b) with employer contributions.
• 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.