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

DescriptionHOW WE CARE FOR YOUAt 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 HolidaysPersonal Time that includes Vacation Time, Sick Time & HolidaysHealth & Wellness Benefits starting Your First DayMedical, Dental & Vision Programs tailored to Your NeedsStudent Loan Repayment ProgramFree ASN to BSN Program through Advance UTuition Assistance & Reimbursement ProgramClinical LadderEmployee Referral Program with Bonuses up to $10kCertification Support and PayRelocation AssistanceAdvancement OpportunitiesRetirement Savings ProgramEmployee Assistance Program including free Mental HealthSame Day Pay through Daily PaySUMMARYThe 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 TimeLOCATION: GIM @Alexander Park, Refugee Clinic @ Alexander ParkDEPARTMENT: Ambulatory Care ManagementSCHEDULE: Monday-Friday, DaysATTRIBUTESBSN (preferred) or Associate's Degree in Nursing (ASN) and a Bachelor's Degree in another disciplineMinimum 405 years of clinical nursing experience: case management/utilization management/ discharge planning experience preferredMust have a NYS driver's licenseProgressive clinical experience including community health, care management, disease management or behavioral health preferredCompassionate, warm and patient focusedStrong interpersonal skillsExperience working as a member of a multidisciplinary teamAbility to lead and facilitate a team approach to population-based careCritical thinking skills, decisive judgementExceptional documentation skills and professional behaviorExcellent written and verbal communication skillsAbility to work independently in a fast-paced environmentProficient computer skills Excel, Word, the Internet and Health Information TechnologyRESPONSIBILITIESIdentify 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 confidentialityFacilitate patient referrals across the care continuum to meet individual patient needsInteract 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 patientsLead practice level care team roundsPHYSICAL 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:RN - Registered Nurse - New York State Education Department (NYSED)BLS - Basic Life Support - American Heart Association (AHA)PAY RANGE: $65,000.00 - $95,000.00The 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/VeteranMinimum Salary: 65000.00 Maximum Salary: 95000.00 Salary Unit: Yearly