The purpose of the Ambulatory Nurse Case Managers is to comprehensively and actively manage the care management and coordination needs of payer defined and/or payer enrolled populations or patients who meet designated inclusion criteria. This includes activities such as assessments, formal Case Management care plan development, establishing goals and intervention and monitoring/tracking. Through these activities, the Ambulatory Nurse Case Manager will partner with physician practices and the care management team related to the clinical and care coordination needs of the patient, as well as work with payers and/or community resources to develop and facilitate effective, efficient care delivery options for the identified at risk patients across the care continuum.
Minimum Work Experience 4 years Nursing experience in case management, ambulatory nursing or community/homecare experience preferred (Required)
Required Skills/Knowledge Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment. Requires superior verbal communication skills and service excellence approach with internal and external stakeholders. Must have strong business writing skills. Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.
Required Licenses and Certifications Registered Nurse in District of Columbia (Required) Licensed RN (Required) Certification in Case Management preferred (Preferred)
Functional Accountabilities Ambulatory Case Management
Provides intensive case management and care coordinationfor higher risk sub-populations defined by federal and third party payers or through case finding and referrals that meet inclusion criteria
Develops and documents comprehensive care plans with clinician and family identified goals
Assesses and monitors patient’s progress on care goals, regularly interfacing with care team and refining the care plan as indicated
Identifies barriers to attaining goals within care plan and mobilizes resources to mitigate barriers
Supports family self-management and patient advocacy through education and communication
Collaboration with Medical Home and Care Management Team
Coordinates and collaborates with physicians and other providers to facilitate provision of effective, efficient services to meet the patient’s complex needs
Maintains care plans in coordination with practices/care delivery system and case management team members
Collaborates with clinical care team as well as case management care team to define interventions to meet the patient's care management needs and any population health goals
Delegates and supervises care management activities to non-nursing team members in accordance with the DC Nurse Practice Act.
Provides or organizes relevant patient education and health coaching, condition-specific as applicable
Transitions of Care
Accepts and facilitates bi-directional Care Transition hand-offs to follow-up of enrolled patients after ED visit, Urgent Care, Observation, Inpatient, SNF stay and transitions to adolescent and adult providers
Works with payers, acute and post-acute care providers/care managers and/or community resources to develop and facilitate effective, efficient, sustainable care delivery options across settings.
Communicates patient care plan and needs to new care teams as patient transitions to different care settings across the continuum.
Guides and support a smooth transition from pediatric to adult care & providers Decide if want separate bulltet point or include in first one
Documentation and Data Management
Documents patient consent for case management and care coordination as required
Documents the plan of care, reviews at designated intervals and updates as needed; shares with physician and patient caretaker
Leverages IT systems to capture data; submit claims for care managementas needed
Monitors data reports and registries to case find patients in need of outreach and/or case management interventions and care coordination
Reviews data outcomes for patient caseload to identify clinical, quality and/or financial metrics that require attention and intervention.