Ambulatory Care Manager (RN)

103 Rochester General Hospital; United States; Hybrid; USD 81,000 - 110,000; Full time

Job summary

103 Rochester General Hospital is seeking an Ambulatory Care Manager (RN) to improve outcomes for high-risk patients across ambulatory practices in NY. The RN collaborates with primary care teams, develops care plans, and connects patients to community resources with telephonic support and home visits.

The role emphasizes care coordination, patient education, and improving access to services within a hybrid work model, with a typical 36-hour week and Mon-Fri schedule.

Qualifications

• For employees hired after October 1, 2020, requires an Associate’s Degree in Nursing (ASN) and a Bachelor’s Degree in another discipline or a BSN.
• Minimum Experience: 5 years of clinical nursing experience required.

Responsibilities

• Provide Care Management Services in collaboration with Practice Leadership: identify high-risk patients and engage them with coordinated care.
• Assess patient condition, needs, preferences and barriers; develop and implement a care plan.
• Coordinate care across primary/specialty medical, mental health and community resources; monitor progress.
• Support patient self-management, ensure language access and participate in care team meetings and training.

Skills

Excel

Word

Health IT

Education

ASN/BSN requirements

Tools

EHR systems

Job 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.
• 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

Required Qualifications

• For employees hired after October 1, 2020, requires an Associate’s Degree in Nursing (ASN) and a Bachelor’s Degree in another discipline - or a Bachelor's in Nursing (BSN). The BSN is preferred but not required.
• Minimum Experience: 5 years of clinical nursing experience required.

Preferred Qualifications

Progressive clinical experience including community health, care management, disease management or behavioral health preferred Compassionate, warm and patient focused Strong interpersonal skills Experience working as a member of a multidisciplinary team Ability to lead and facilitate a team approach to population-based care Critical thinking skills, decisive judgement Exceptional documentation skills and professional behavior Excellent written and verbal communication skills Ability to work independently in a fast-paced environment Proficient computer skills Excel, Word, the Internet and Health Information Technology

Licenses / Certifications

BLS - Basic Life Support - American Heart Association (AHA), RN - Registered Nurse - NYS Office of Professions

Physical Requirements

Light - Clinical - Light clinical roles involve frequent standing and walking, with occasional lifting of light objects (≤20 lbs.) and routine reaching, grasping, and fine manipulation for tasks such as patient care, laboratory work, or specimen processing. Staff rely on strong visual and auditory acuity to accurately observe specimens, read instrumentation, monitor patients, respond to alarms, and communicate effectively with care teams. Cognitive demands include multitasking, prioritizing clinical and laboratory workflows, and coordinating with interdisciplinary teams. Emotional resilience is necessary due to frequent interruptions, shifting priorities, and the need for precise and compassionate interaction with patients and colleagues. Environmental exposures may include infectious materials, biological specimens, cleaning agents, sharps, chemical reagents, and wet surfaces. PPE use, TB testing, and schedule flexibility are commonly required. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

Pay Range

$80,753.00 - $110,292.00 CITY: Rochester POSTAL CODE: 14617 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Equal Opportunity Statement

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law. Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials. It’s vision is to lead the evolution of healthcare to enable every member of the communities it serves to enjoy a better, healthier life.