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
Specific Requirements and Preferences
Nursing experience in case management, ambulatory nursing or community/homecare experience preferred (Required)
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 Req
Licensed RN Req
Certification in Case Management preferred
Ambulatory Case Management
1. 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
2. Develops and documents comprehensive care plans with clinician and family identified goals
3. Assesses and monitors patient’s progress on care goals, regularly interfacing with care team and refining the care plan as indicated
4. Identifies barriers to attaining goals within care plan and mobilizes resources to mitigate barriers
5. Supports family self-management and patient advocacy through education and communication
Collaboration with Medical Home and Care Management Team
1. Coordinates and collaborates with physicians and other providers to facilitate provision of effective, efficient services to meet the patient’s complex needs
2. Maintains care plans in coordination with practices/care delivery system and case management team members
3. 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
4. Delegates and supervises care management activities to non-nursing team members in accordance with the DC Nurse Practice Act.
5. Provides or organizes relevant patient education and health coaching, condition-specific as applicable
Transitions of Care
1. 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
2. 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.
3. Communicates patient care plan and needs to new care teams as patient transitions to different care settings across the continuum.
4. 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
1. Documents patient consent for case management and care coordination as required
2. Documents the plan of care, reviews at designated intervals and updates as needed; shares with physician and patient caretaker
3. Leverages IT systems to capture data; submit claims for care managementas needed
4. Monitors data reports and registries to case find patients in need of outreach and/or case management interventions and care coordination
5. Reviews data outcomes for patient caseload to identify clinical, quality and/or financial metrics that require attention and intervention.
Organizational Accountabilities (Staff)
1. Anticipate and responds to customer needs; follows up until needs are met
1. Demonstrate collaborative and respectful behavior
2. Partner with all team members to achieve goals
3. Receptive to others’ ideas and opinions
1. Contribute to a positive work environment
2. Demonstrate flexibility and willingness to change
3. Identify opportunities to improve clinical and administrative processes
4. Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
1. Use resources efficiently
2. Search for less costly ways of doing things
1. Speak up when team members appear to exhibit unsafe behavior or performance
2. Continuously validate and verify information needed for decision making or documentation
3. Stop in the face of uncertainty and takes time to resolve the situation
4. Demonstrate accurate, clear and timely verbal and written communication
5. Actively promote safety for patients, families, visitors and co-workers
6. Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance