Description
The Central Market RN Ambulatory Care Manager delivers comprehensive ambulatory care management services to identified patients. Leveraging clinical expertise, this role involves conducting care management screenings, assessments, and evaluations. The manager develops and implements patient-centred care plans with shared goals and appropriate interventions. Collaborating effectively with patients, families/caregivers, healthcare providers, payers, community-based providers, and other involved parties ensures efficient, effective, and patient-centred care management services. The role operates across various settings, including transitions of care, clinics, communities, and post-acute care environments, and supports proactive care for at-risk patients.
Essential Functions
- Patient Identification and Assessment: Identify patients for proactive interventions using specific screening criteria, medical record review, payor models, medical risk scores, or referrals. Assess patients' medical, functional, and social conditions per department policy/guidelines to develop individualised care plans and connect them with community resources.
- Care Plan Management: Develop, maintain, and monitor patient care plans consistent with NCQA and department policies/guidelines, ensuring adherence to medical plans and focusing on prevention measures. Coordinate internal and external services for SDoH needs and care in the community. Evaluate the effectiveness of the patient’s care plan and outcomes. Modify the plan of care or specific interventions, as appropriate.
- Patient Support: Support patient self-management and behaviour change using motivational interviewing and coaching techniques. Assess patient readiness and capacity for change and confidence in self-care.
- Education and Advocacy: Educate healthcare team members about case management processes, appropriate referrals, and advocate for patient rights. Educate patients about their medical/behavioural health conditions and self-management.
- Multidisciplinary Collaboration: Collaborate with physicians and other healthcare team members on the patient’s behalf to ensure the patient receives quality and timely care and resolves any delays or issues. Participate in rounds or case conferences when necessary. Utilise team-based care approach referring and consulting with social work, nutrition, pharmacy, rehabilitation, behavioural health, etc. resources as appropriate.
- Relationship Building: Develop and maintain collaborative partnerships with hospital care management, post-acute providers, and other care managers to ensure seamless transitions and continuity of care. Avoid duplicative care management services/programs.
- Process Improvement: Actively participate in system and regional initiatives to improve transitions of care and avoid duplicative services.
- Advanced Care Planning: Facilitate advanced care planning and engage in patient and family care conferences as appropriate.
- Data Analysis: Conduct root cause analysis of extended post-acute stays, inappropriate utilisation, readmissions, and track key data elements or metrics. Identify, analyse, and monitor industry, regulatory, technology, and market-based trends that impact ambulatory and post-acute services.
Minimum Qualifications
- Current Registered Nurse (RN) license in state of practice.
- Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion.
- Demonstrated clinical nursing experience in chronic disease management, and familiarity with chronic disease terminology and processes.
- Proficiency in basic computer skills and Microsoft Office software.
Preferred Qualifications
- Care Management Certification
- Demonstrated experience in case management, utilisation review, or discharge planning.
Work Schedule: Monday - Friday 8:00am - 4:30pm, 2 days a week in clinic
Salary: $41.20 - $62.17 per hour