Ambulatory Care Manager (RN) - Alex Park
Rochester Regional Health

Job Info

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Description

HOW WE CARE FOR YOU

At Rochester Regional Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

• No Weekends or Holidays
• Personal Time that includes Vacation Time, Sick Time & Holidays
• Health & Wellness Benefits starting Your First Day
• Medical, Dental & Vision Programs tailored to Your Needs
• Student Loan Repayment Program
• Free ASN to BSN Program through Advance U
• Tuition Assistance & Reimbursement Program
• Clinical Ladder
• Employee Referral Program with Bonuses up to $10k
• Certification Support and Pay
• Relocation Assistance
• Advancement Opportunities
• Retirement Savings Program
• Employee Assistance Program including free Mental Health
• Same Day Pay through Daily Pay

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.

STATUS: Full Time

LOCATION: Genesee Internal Medicine and Refugee Clinic

DEPARTMENT: Ambulatory Care Management

SCHEDULE: Monday-Friday, Days

ATTRIBUTES

• BSN (preferred) or Associate's Degree in Nursing (ASN) and a Bachelor's Degree in another discipline
• Minimum 405 years of clinical nursing experience: case management/utilization management/ discharge planning experience preferred
• Must have a NYS driver's license
• 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

RESPONSIBILITIES

• Identify high risk populations that meet eligibility requirements for complex care management services using standard analytics and referral sources including reports and patient registries. Monitor and analyze utilization of health care services including IP, ED and 30-day readmission visit with appropriate follow up. Complete a comprehensive nursing assessment that includes assessment of the social drivers and other gaps or barriers to health. Develop an individualized, patient centered care management plan based on the patient's preferences and goals, strengths and barriers that promote improved health care outcomes and quality of life in collaboration with patient, family, caregivers and other members of the healthcare team. Identify resources and provide education to assist patients in developing self-management skills that considers the patient's health literacy level. Identify and utilize a network of resources within and without the healthcare system to promote effective care management.
• 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.
• 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.
• Maintain the physical and technical security and privacy of protected health information (PHI) to maintain confidentiality
• Facilitate patient referrals across the care continuum to meet individual patient needs
• Interact effectively with PCPs/ providers and other members of the health care and/or community teams to implement patient interventions that mitigate barriers to healthcare.
• Collaborate with Social Work partner on proactive patient outreach and assessment of high risk patients
• Lead practice level care team rounds

PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

LICENSES/CERTIFICATIONS:

• BLS - Basic Life Support - American Heart Association (AHA)
• RN - Registered Nurse - New York State Education Department (NYSED)

PAY RANGE: $79,560.00 - $109,200.00

The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

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