TCHP Care Manager-RN - Ft Wright Care Management - Full Time - Days

The Ambulatory Care Manager (RN) provides comprehensive clinical care management services to identified eligible patients across the healthcare continuum. This role focuses on coordinating care to improve health outcomes, enhance patient self-management, reduce unnecessary utilization, and ensure cost-effective, high-quality care. The Care Manager performs standardized comprehensive assessments, identifies and addresses barriers to care, and collaborates with patients, providers, and the interdisciplinary care team to develop and implement individualized care plans. The role primarily supports high-risk patients with multiple comorbidities or increased risk for hospital admission or readmission and facilitates seamless care transitions following inpatient or emergency department encounters. The role’s high-level goal is to reduce readmissions by facilitating smooth transitions and identifying and mitigating risks. The Ambulatory Care Manager (RN) provides comprehensive clinical care management services to identified eligible patients across the healthcare continuum. This role focuses on coordinating care to improve health outcomes, enhance patient self-management, reduce unnecessary utilization, and ensure cost-effective, high-quality care. The Care Manager performs standardized comprehensive assessments, identifies and addresses barriers to care, and collaborates with patients, providers, and the interdisciplinary care team to develop and implement individualized care plans. The role primarily supports high-risk patients with multiple comorbidities or increased risk for hospital admission or readmission and facilitates seamless care transitions following inpatient or emergency department encounters. The role’s high-level goal is to reduce readmissions by facilitating smooth transitions and identifying and mitigating risks. ### Responsibilities **Care Management** - Serve as a clinical care management resource for providers and clinical teams - Maintain an assigned caseload in accordance with departmental policies - Identify, enroll, and manage patients in Transitions of Care and Chronic Disease Management programs - Utilize Motivational Interviewing techniques to engage and activate patients in self-management of chronic conditions - Conduct comprehensive assessments to identify clinical, psychosocial, and social determinants of health - Develop, implement, and review individualized care plans in collaboration with the care team - Perform medication reconciliation and teach-back to ensure patient understanding and adherence - Coordinate care transitions following inpatient or emergency department encounters to promote continuity of care - Collaborate with PCPs, specialists, hospitalists, and other providers to implement patient-centered care plans - Conduct patient outreach per established protocols and document appropriately in the electronic medical record - Identify, initiate, and track referrals to internal services and community resources - Educate patients on self-management strategies to improve health outcomes - Assist patients with advance care planning, including completion of advance directives - Document all patient and care team interactions in the electronic medical record **Clinical Quality and Performance** - Partner with providers and clinical staff to ensure clinical quality remains a priority throughout the care continuum - Participate in clinical quality initiatives and support implementation of evidence-based best practices - Collaborate with professional colleagues and community agencies to promote best practices in care management - Coordinate with physician leadership to develop strategies for managing high-risk patient populations - Monitor utilization of healthcare resources and promote appropriate, efficient use - Contribute to the development of office workflows and care standards for preventive services and chronic disease management - Lead through influence and role modeling effective nursing pr…