Registered Nurse Ambulatory Care Manager (RN) - Population Health

In the capacity of a Registered Nurse (RN), the Ambulatory Care Manager 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. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources.  Collaborate with patient, provider and care team to develop and implement a 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 Virginia (VA) market.

Essential Job Functions

• 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.

Employment Qualifications

Associate’s Degree (required)

Specialty/Major- Nursing

Bachelor’s Degree (preferred)

Specialty/Major- Nursing (BSN)

Licensing/ Certification

Registered Nurse with active License in State of Patient Care (required)

Case Management certification (CCM) (preferred)

Minimum Qualifications

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

Other Knowledge, Skills and Abilities

• 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)

Patient Population

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

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.  

Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.

Neonates (0-4 weeks)

Adolescents (13-17 years)

Infant (1-12 months)

Adults (18-64 years).

Pediatrics (1-12 years)

Geriatrics (65 years and older)