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Registered Nurse Ambulatory Care Manager – Population Health
Easyservice ItaliaRegistered Nurse providing clinical care management services for patients in the Virginia area. Collaborating with healthcare teams to improve patient outcomes and manage care effectively.
About the role
Key responsibilities & impact- 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.
- 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.
Requirements
What you’ll need- Associate’s Degree (required) Specialty/Major- Nursing
- Bachelor’s Degree (preferred) Specialty/Major- Nursing (BSN)
- Registered Nurse with active License in State of Patient Care (required)
- Case Management certification (preferred)
- 2-3 years acute care, home health or case management experience
- Excellent interpersonal communication and negotiation skills.
- Strong analytical, data management and computer skills.
Benefits
Comp & perks- Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
- Medical, dental, vision, prescription coverage, HSA/FSA options, life insurances, mental health resources and discounts
- Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
- Tuition assistance, professional development and continuing education support
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical care managementcomprehensive needs assessmentMotivational Interviewingcare plan developmentmedication reviewadvanced care planningdata managementpatient outreachreferral managementchronic disease management
Soft Skills
interpersonal communicationnegotiation skillsanalytical skills
Certifications
Registered Nurse LicenseCase Management certification