Ambulatory Chronic Care Manager (RN)

Yale New Haven Health; New Haven (CT); Remote; USD 75,000 - 105,000; Full time

Job summary

Yale New Haven Health is seeking an Ambulatory Chronic Care Manager (RN) to improve health outcomes, focusing on patients in value-based contracts. You will conduct nursing assessments, develop action plans, and coordinate care with a multi-disciplinary team, promoting patient-centered education and addressing social determinants impacting care.

The role supports care transitions, medication reconciliation, and advocacy for patients and families, with a primary remote work arrangement and

Qualifications

• Minimum of a Baccalaureate degree in clinically related field.
• CT RN license required.
• Minimum of 3 years of combined clinical experience in direct patient care and care coordination.
• Certified Case Manager (CCM) or accredited equivalent preferred.

Responsibilities

• Enrols patients in chronic care management programs, establishing a therapeutic relationship for the duration of the program.
• Collaborates with a multidisciplinary healthcare team on care plans and rounds.
• Applies evidence-based practice and clinical guidelines to patient care plans and interventions.
• Performs other duties as required or requested.

Skills

Care management

Chronic disease management

Transitions of care

Interdisciplinary teamwork

Motivational interviewing

Communication skills

Education

Baccalaureate degree in clinically related field

CT RN license required

Job description

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Ambulatory Chronic Care Manager (RN) is as a member of the enterprise Ambulatory Care Management team and is accountable for improving the health outcomes for all patients, with a particular focus on patients in value-based/risk contracts. The Ambulatory Chronic Care Manager (RN) works as part of a multi-disciplinary team under the direction of the Ambulatory Care Management leadership. The Ambulatory Chronic Care Manager (RN) is responsible for performing nursing assessments, evaluations, screenings, and development of action plans to mediate gaps in clinical care. The role will participate in all components of care management including, but not limited to, management of care transitions, medication reconciliation/review, provide patient-centered education related to acute or chronic illnesses, evaluate for social determinants and barriers that impact care management , adhere to quality metrics, facilitate communication among providers, and advocate for the patient, family, and support system.

EEO/AA/Disability/Veteran

Responsibilities

• 1.Demonstrates an understanding of care management, complex disease management, transitions of care , post-acute care options, and community management standards.
  • 1.1Outreaches to and enrolls patients in chronic care management programs, establishing a therapeutic relationship and managing the patient's engagement for the duration of the program
• 2.Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team.
  • 2.1Participates interdisciplinary team rounds to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
• 3.Demonstrates an understanding of clinical standards, quality performance goals, and expected outcomes.
  • 3.1Demonstrates application of evidence-based practice and clinical practice guidelines to care plans and patient interventions.
• 4.Performs other duties as required or requested.

Qualifications

EDUCATION

Minimum of a Baccalaureate degree in clinically related field. CT R.N. license required.

EXPERIENCE

Minimum of 3 years of combined clinical experience in direct patient care and care coordination/case management in an acute, community, or post-acute provider or health plan.

LICENSURE

RN Licensure in Connecticut required; Certified Case Manager (CCM) or accredited equivalent certification preferred.

SPECIAL SKILLS

Motivational interviewing skills necessary. Excellent verbal and written communication skills. Excellent organizational skills and ability to handle multiple priorities. Ability to work in an independent role with minimal supervision. Functions as an integral team member and demonstrates flexibility in sharing responsibilities. Validated translation capability preferred. Working knowledge of computers and basic software applications used in job functions, such as word processing , databases, spreadsheets, and others as needed.

PHYSICAL DEMAND

Role is primarily a remote work position with the ability and expectation to travel to onsite practice locations from time to time as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards.

Additional Information

Spanish speaking highly preferred.