RN Case Manager | Ambulatory

The Ambulatory Nurse Case Managers 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.

This role supports the Care Connections Program, a network of services aimed at supporting families by connecting them with necessary resources, navigating complex healthcare situations, and providing emotional support, essentially acting as a bridge between the hospital and the community to ensure patients receive comprehensive care beyond just medical treatment; this could include assistance with social services, educational tools, and coordinating care with other providers.

Minimum Education
BSN (Required)
Master's Degree (Preferred)

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.