Job Description

Summary of Position

Under the direction of the Manager of Care Management, the Ambulatory Care Manager (ACM) coordinates and manages all aspects of patient care for the high and rising risk population through multiple care delivery systems, acting as the central point of contact for patients, supporting them through transitions of care. Receives care management reports and PCP referrals to target high risk patients to ensure quality care and patient safety. Through initial contact and assessment, establishes active partnerships with patients and clinical partnerships with PCPs, specialists, IM leadership and staff, and internal and external resources. Reports to the Manager of Care Management.

Essential Functions

•In collaboration with the patient's primary and specialty providers, the ACM, as a member
of the care team, works with high and very high risk patients and those with chronic and complex medical conditions. Develops a self-management action plan of care, coordinates services and navigates the patient through the health care system with a goal of enabling the patient and family to effectively manage their condition(s) and optimize outcomes.

•Performs a comprehensive care management assessment of patient needs to ensure safety at
home, utilizing evaluative assessment tools in the system's Care Management module, such as initial, falls risk, and caregiver assessments. As needed, coordinates effective transitions of care and effective handoffs to the next level of care across the entire continuum.

•Utilizes available reports to proactively prioritize the needs of the high risk
patients and coordinates interventions. Conducts outreach to keep these initial targeted
populations aligned by PCP based on risk stratification and other criteria.

•Designs transition of care plans with the patient. Collaborates with the patient/family,
hospital team, primary care team, specialists, SCHN Medical Director, Extended Care Case Managers, Social Workers, Wellness Coordinators and other Steward Health Care Network
programs, community services, and other members of the health care team to ensure safe
transitions of care, effective coordination of services, and full understanding and execution
of the care plan.

•Actively reviews available reports, considers care management (CM) impact; recommends
and makes modifications to the plan of care, as needed.

•Maintains required medical documentation for case management activities in The system's Care Management module (electronic medical records), according to the standards of work.

•Evaluates processes, identifies problems, and proposes improvement strategies to enhance
the delivery of care for patients throughout continuum of care. Maintains awareness of key performance indicators/metrics and manages caseload through appropriate management of medical expenses. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions and readmissions.

•Actively participates in the roster review and other collaborative care initiatives with the
practice staff for data collection, health reporting outcomes, clinical audits and
programmatic evaluations.

•Follows standards of work and consistently maintains department established caseloads
and timeframes for case completion. Participates in the refinement of and development of new standards of work.

•Meets regularly 1-1 with the Manager of Care Management to review caseload and discuss
barriers/challenges and review performance compared to current targets/expectations.

•Documents and reports all quality and patient safety events by recording and adhering to
all of Steward Health Care Network's safety reporting guidelines.

•Performs all job functions in compliance with applicable federal, state, local and company
policies and procedures. Stays current with medical, nursing and pharmacological Evidence Based Guidelines (EBGs) for the care of patients with complex and chronic conditions.

Non-Essential Functions

Performs other duties as needed. Any other duties performed which are not listed as essential
functions are considered non-essential functions.

Minimum Requirements

Education (or equivalent education, training or experience):

Graduate of a state-approved school of
nursing, BSN preferred; Certified Case Management (CCM) or CCM eligible strongly preferred.
Possess a current unrestricted RN licensure in the Commonwealth of Massachusetts. Must
maintain Basic Cardiac Life Support (BCLS) certification.

Skills and Experience:

Minimum of 3-5 years' relevant clinical nursing experience required,
experience in Care Management is strongly preferred. Must exhibit strong critical thinking,
problem solving, interpersonal and good patient interviewing skills. Highly motivated and
self-directed. Ability to interpret clinical information, assess the implication of treatment and
develop and implement a plan of care. Demonstrated ability to prioritize, multitask, and work
in a rapidly changing environment with multiple demands. Ability to utilize tools for the effective documentation of the care management process. Ability to work effectively in a
team. Ability to travel to select practice sites for meetings with patients, PCP and other members of the care team.

Application Instructions

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