Registered Nurse Ambulatory Care Manager (RN) - Population Health

With a legacy that spans over 150 years, Bon Secours is a network that is dedicated to providing excellent care through exceptional people. At every level, everyone on our teams have embraced the call to provide compassionate care. Here, you can work with others who share common values, and use your skills to help extend care to all of our communities.

In the capacity of a Registered Nurse (RN), the Ambulatory Care Manager will provide clinical care management services to identified eligible patients; coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources. Collaborate with patient, provider and care team to develop and implement a plan of care to ensure medically appropriate cost-effective care. ***This position is primarily remote/work from home. Hire must be able to go onsite up to 20% to support the Hampton Roads Virginia (VA) market.

Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management of their chronic conditions with the goal of improved symptom management and interruption of a negative disease trajectory Maintain a caseload of patients according to department policies. Identify, enroll and manage patients in program for Transitions of Care/Complex Case Management/Chronic Disease Management. Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols. Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen. Collaborate with PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan. Perform patient outreach according to established protocols and document in electronic medical record. Identify, execute, and track needed referrals to care and community resources. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time. Assist patient in advanced care planning to complete Advanced Directives. Document all communications with patient and/or care team in electronic medical record. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.