Summary:
The Ambulatory Care Manager is assigned to manage a panel of patients and work together with primary care providers and members of the Care Management team. The Ambulatory Care Manager is responsible for coordinating care to obtain desired health outcomes, improve self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. The Ambulatory Care Manager utilizes evidence-based medicine, data analytics, and innovation in implementing care management principles to meet patients and their families' needs. This position applies principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and adjusts patient assignments accordingly. The Ambulatory Care Manager performs standardized comprehensive needs assessments, determines available benefits and resources, and develops and implements a plan of care for assigned patients that includes performance goals, monitoring, follow-up, and outreach activities. Patients assigned to the Ambulatory Care Managers can include but are not limited to: complex patients whose critical event or diagnosis requires extensive use of resources, and who need help navigating the system to facilitate appropriate delivery of care and services; transitional care management focused on evaluating and coordinating post-hospitalization needs of patients at risk for rehospitalization, and high-risk, high-cost patients who frequently use emergency department services or have frequent hospitalizations. The Plan of Care is created based on the results of the comprehensive needs assessment performed by the Care Manager through extensive medical record review, face-to-face and/or telephonic encounters with assigned patients and families where appropriate. Performance goals are focused on resolution of critical events, control of chronic disease, decrease avoidable admissions and readmissions; safe care transitions, improvement in self-management skills while providing extraordinary patient experience.
Responsibilities:
- In conjunction with the primary care provider, perform key care management services.
- Each service has standardized protocols of delivery and documentation.
- Outreach and health promotion services.
- Comprehensive assessment with required documentation.
- Coordination of referrals and transitions of care from one provider to another or from one care setting to another.
- Medication reconciliation and adherence.
- Facilitation and/or procuring timely access to appointments and services required by patient.
- Patient and Family/Caregiver education.
- Evaluation of effectiveness of care plan with IDT.
- Evaluate baseline medical and psychosocial evaluations with patient, and create individualized patient care/treatment plans in conjunction with transition care specialists, care coordinators, and partners with primary care and specialties.
- Assess patient and family's ability to self-engage, and develop individualized education plans focused on self-management skills based on System's standard care protocols.
- Advise and educate patient, family, and caregiver on importance of medication adherence.
- Identify patients with special needs, and facilitate integration of primary care with specialty and other services such as behavioral, social, and community services where appropriate.
- Plan, develop, assess, and evaluate care provided to specific patient populations, and engage team of transitional care specialists and care coordination to divide workload among team where appropriate.
- Recommend alternative levels or modalities of care, and ensure compliance with federal, state, and local requirements.
- Advocate for the completion of living wills and advance care planning, and, when appropriate, begin palliative care consultations.
- Develop and collect data; analyze utilization of health care resources, including interpretation and application to case load decision making.
- Perform analysis of the effectiveness and appropriateness of patient care plan; and modify care plan based on assessment and evaluation.
- Communicate clear, complete, and accurate documentation in a health record to ensure that all those involved in a client's care have access to necessary information to plan and evaluate their interventions.
- Update plan of care to ensure all care team members have timely information regarding the patient's status.
- Other duties as assigned by the Supervisor, Ambulatory Care Management.
QUALIFICATIONS / REQUIREMENTS:
5+ years of acute care/ambulatory care experience. Care management experience in ambulatory setting or health insurance and other payer entities preferred. Knowledge of national care management standards and community resources highly preferred.
EDUCATION:
Registered Nurse, bachelor's degree preferred, or Licensed Clinical Social Worker or equivalent.
Licenses / Certifications:
Case/Care Management certification preferred.
About Us:
Bon Secours Charity Medical Group
Bon Secours Charity Medical Group, part of Bon Secours Charity Health Systems (BSCHS), a regional network of more than 120 primary care physicians and specialists from a broad array of medical specialties. BSCHS, a member of WMCHealth Network, includes Good Samaritan Hospital in Suffern, NY, Bon Secours Community Hospital in Port Jervis, NY, and St. Anthony Community Hospital in Warwick, NY.
Benefits:
We offer a comprehensive compensation and benefits package that includes:
- Health Insurance
- Dental
- Vision
- Retirement Savings Plan
- Flexible Savings Account
- Paid Time Off
- Holidays
- Tuition Reimbursement
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