Ambulatory Care Manager - RN- Sign On Bonus!
Company: Rochester General Health System
Posted on: June 7, 2021
A registered nurse, working in collaboration with primary care
providers and care team to identify and proactively manage the
needs of patients with high risk or complex medical, behavioral
health and/or psychosocial problems through practice, community and
home based visits and telephonic support. The Care Manager develops
and implements a care management plan based on patient goals,
preferences and disease states to promote improved health care
outcomes and quality of life. The care manager links patients to
appropriate community resources, facilitates referral to
appropriate care services, supports patient self-management, and
communicates with providers in order to reduce barriers to improved
health care outcomes. The Care Manager serves as an integral member
of the primary care practice's care team, assesses patients for
risk of adverse health outcomes, and measures the impact of care
STATUS: Full Time
LOCATION: Riedman Campus
DEPARTMENT: Care Management
- BSN required within five years of hire or Care Manager
Certification required within three years for hired on or after May
- Registered Nurse license in New York State.
- Minimum Experience: 5 years of clinical nursing experience with
3-5 years of community health experience preferred.
- Knowledge of community resources required
- Excellent communication skills and ability to form
collaborative partnerships across all service settings
- Good listening skills
- Sound reasoning and problem solving skills
- Ability to assimilate new information and technologies into
- Strong computer skills: Competent in Microsoft Office products
(Word, Excel, Outlook, PowerPoint)
- Ability to interact with individuals with diverse cultural and
- Experience in Care Management preferred.
- Working knowledge of the provision of health care in a variety
of settings preferred.
In collaboration with Practice Leadership (clinical and
non-clinical), provides Care Management Services:
- Identify or work with others to identify patients with high
risk of adverse health outcomes (e.g. death, disability, inpatient
admission, SNF admission or ED visit.).
- Engage patients in trusting relationships enabling effective
intervention and support.
- Conduct an assessment of patient condition, needs, preferences
and clinical and psychosocial barriers.
- Support the patient in identification of actionable goals to
optimize health outcomes.
- Develop a care management plan based on the patient's goals,
strengths and barriers that promote improved health care outcomes
and quality of life.
- Provide culturally competent interventions based on member
assessment and identified cultural needs.
- Implement the patient approved plan of care in collaboration
with the practice care team and patient through practice, community
and home based visits and telephonic support:
- Provide comprehensive care management including self-management
support, health promotion, connection/referral to appropriate
physical/mental health/substance abuse providers and community
based organization social supports to decrease barriers to
attending appointments and following the plan of care, red flag
- Utilize Self-Management Support interventions to promote
self-advocacy. Monitor the patient's level of activation relative
to their health goals over time.
- Advocate for patients to assure access and timely service
delivery across the continuum of care and community resources.
- Provide education/ information to patients/caregivers in
support of care plan goals.
- Optimize insurance and other benefits to support patient access
to needed services.
- Provide care coordination with Primary/Specialty Medical care,
acute and outpatient medical, mental health and substance abuse
services, and other care managers involved in supporting the
- Provide comprehensive transitional care involving coordination
of care and services post critical events, such as emergency
department use, hospital inpatient admission and discharge or
skilled nursing facility admission and discharge;
- Work with the attending/consulting physicians to facilitate
effective transition through timely communication of information
necessary for patient care and discharge planning, and supporting
appropriate patient self-management.
- Provide crisis intervention planning addressing events such as
emergency department visits or inpatient admissions or other crisis
events to ensure planned crisis interventions are effective and to
make necessary modifications of the Plan of Care or need for
additional support services;
- Conduct medication reconciliation as appropriate and
communicate needs for adjustments to care team/provider;
- Provide patient education; facilitate solutions to patient care
- Work with family regarding the patient's needs; assess
caregivers burdens; provide family and caregiver support;
- Ensure language access/ translation capability;
- Review patient progress no less frequent than quarterly;
- Modify goals and care management interventions as appropriate
to the needs/progress of the individual;
- Share information (e.g. progress, barriers, new conditions,
etc.) between Team members and other care providers;
- Participate in Care Team meetings, training, and other
functions as required
- Meet practice policy and procedures related to documentation of
care management activities and their effectiveness in a practice
- Handle confidential information in accordance with HIPAA, state
and federal privacy and confidentiality rules.
- Participates effectively as a Team member within the
- Foster a positive working relationship with patients, providers
and practice staff;
- Work effectively with others to coordinate patient and access
care support services;
- Provide input relating to changes that may enhance the practice
- Participate in meetings and huddles as appropriate;
- Conduct pre-visit planning and post-visit follow-up for care
- Provide feedback to providers regarding patient progress and
- Prepare for and participate in case review meetings to share
cases, discoveries, concerns and collaborate in the development of
plans of care.
- Collect and provide reports of activities as required
- Care Manager will participate in all scheduled meetings and
- Shares updated information related to appropriate community
- Identifies opportunities to improve processes and services.
Shares with Practice and Leadership issues that are obstacles to
meet patient need.
- Performs other duties as assigned.
- Work hours as scheduled, may require some evenings and weekend
dependent upon population needs
Rochester General Health System is an Equal Opportunity /
Affirmative Action Employer.
Keywords: Rochester General Health System, Rochester , Ambulatory Care Manager - RN- Sign On Bonus!, Other , Rochester, New York
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