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Ambulatory Care Manager - RN- Sign On Bonus!

Company: Rochester General Health System
Location: Rochester
Posted on: June 7, 2021

Job Description:


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 management interventions.

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 1st, 2014.
  • 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 daily work
  • Strong computer skills: Competent in Microsoft Office products (Word, Excel, Outlook, PowerPoint)
  • Ability to interact with individuals with diverse cultural and religious customs
  • 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 education, etc.;
  • 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 individual;
  • 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 /delivery problems;
  • 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 software tool;
  • Handle confidential information in accordance with HIPAA, state and federal privacy and confidentiality rules.
  • Participates effectively as a Team member within the Practice:
  • 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 effectiveness;
  • Participate in meetings and huddles as appropriate;
  • Conduct pre-visit planning and post-visit follow-up for care managed patients;
  • Provide feedback to providers regarding patient progress and barriers encountered;
  • 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 training opportunities;
  • Shares updated information related to appropriate community resources
  • 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. Minority/Female/Disability/Veteran.

Keywords: Rochester General Health System, Rochester , Ambulatory Care Manager - RN- Sign On Bonus!, Other , Rochester, New York

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