Ambulatory Care Manager (RN)

Description Job Title: Ambulatory Care Manager (RN) Location: Riedman Health Center - 1455 East Ridge Road Irondequoit, NY (supporting practices of the ambulatory clinical network). Potential for hybrid work (a day or 2/month) in the future. Hours Per Week: 36 Schedule: Monday-Friday 8am-4:30pm SUMMARY: The central role of the RN Care Manager is a commitment to improve clinical outcomes in patient populations most at risk within practices and those at potential risk for adverse healthcare outcomes. The Registered Nurse works in collaboration with primary care providers and the multidisciplinary care team to identify and proactively manage the needs of patients with high risk or complex medical, behavioral health and/or psychological problems through practice, community and home-based visits and telephonic support. The RN 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 RN 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 RN 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. Provide superior customer service by modeling the Brand Promise and Core Values of the organization. RESPONSIBILITIES: 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. Pro