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E

Registered Nurse Ambulatory Care Manager – Population Health

Easyservice Italia

Registered Nurse providing clinical care management services for patients in the Virginia area. Collaborating with healthcare teams to improve patient outcomes and manage care effectively.

Posted 6/17/2026full-timeNorfolk • Virginia • 🇺🇸 United StatesMid-LevelSeniorWebsite

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills
clinical care managementcomprehensive needs assessmentMotivational Interviewingcare plan developmentmedication reviewadvanced care planningdata managementpatient outreachreferral managementchronic disease management
Soft Skills
interpersonal communicationnegotiation skillsanalytical skills
Tools & Technologies
electronic medical record
Certifications & Qualifications
Registered Nurse LicenseCase Management certification
Industry Keywords
acute carehome healthpatient-centered careTransitions of CareComplex Case Managementwellness facilitationcost-effective careself-managementpatient experienceadvanced directives

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