Job Details:

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 Manger 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, performance of standardized comprehensive needs assessment, determination of available benefits and resources; and development and implementation of 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 require 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 the following key care management services are performed.
• Each of these services 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.
• Evaluates baseline medical and psychosocial evaluations with patient, and creates individualized patient care/treatment plans in conjunction with transition care specialists, care coordinators, and partners with primary care and specialties.
• Assesses patient and patient’s family on ability to self-engage, and develops individualized patient and patient’s family education plan focused on development of self-management skills based on System’s standard care protocols.
• Advises and educates patient, patient’s family and caregiver on importance of medication adherence.
• Identifies patients with special needs, and facilitates integration of primary care with specialty and other services such as behavioral, social and community services where appropriate.
• Plans, develops, assesses, and evaluates care provided to specific patient populations, and engages team of transitional care specialist(s) and care coordination to divide workload among team where appropriate.
• Recommends alternative levels or modalities of care, and ensures compliance with federal, state, and local requirements.
• Advocates the completion of living wills and advance care planning, and, when appropriate, begins palliative care consultations.
• Develops and collects data; analyzes utilization of health care resources, including interpretation and application to case load decision making.
• Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
• Communicates 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.
• Updates 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 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

OTHER:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

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.