Registered Nurse, Ambulatory Care Manager – Population Health

• Provide clinical care management services to identified eligible patients
• Coordinate care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care
• Perform standardized comprehensive needs assessments, identify barriers to care, and align patients with benefits and resources
• Collaborate with patients, providers, and care teams to develop and implement medically appropriate, cost-effective care plans
• Use Motivational Interviewing to activate patients in self-management of chronic conditions
• Maintain a caseload according to department policies
• Identify, enroll, and manage patients in Transitions of Care, Complex Case Management, and Chronic Disease Management programs
• Review and update care plans according to department protocols
• Perform medication reviews and teach-back
• Collaborate with PCPs, Specialists, and Hospitalists
• Conduct patient outreach and document in the electronic medical record
• Identify, execute, and track referrals to care and community resources
• Provide resource management to improve care, patient experience, and utilization
• Assist patients with advanced care planning and Advanced Directives
• Document communications with patients and care teams in the electronic medical record

• Associate’s Degree in Nursing required
• Bachelor’s Degree in Nursing (BSN) preferred
• Active Registered Nurse license in the state of patient care 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 improving the health of a distinct ambulatory or community patient population preferred
• Knowledge and skills to provide age-appropriate care to assigned patients
• Knowledge of life-span growth and development principles
• Ability to assess patient-status data and interpret information to identify patient requirements

Demonstrates expertise in clinical care management, including care coordination, patient assessment, and chronic disease management. Proficient in utilizing Motivational Interviewing techniques to enhance patient self-management and improve health outcomes.

• Registered Nurse License
• Case Management Certification
• Chronic Disease Management
• Motivational Interviewing
• Patient Outreach

• Clinical Care Management
• Comprehensive Needs Assessment
• Medication Review
• Data Management
• Care Plan Development

• Interpersonal Communication
• Negotiation Skills
• Analytical Skills

• Registered Nurse License
• Case Management Certification

• Transitions of Care
• Complex Case Management
• Chronic Disease Management
• Patient Experience
• Advanced Directives

• Electronic Medical Record