JOB SUMMARY:
The Nurse Care Manager provides professional, patient centered nursing care in the ambulatory setting in accordance with the multi-disciplinary plan of care and established policies and procedures, under the supervision of the Lead Nurse. Provides direct nursing and telephonic services to patients and families in accordance with the standards of practice for Ambulatory Care Nursing. Collects and analyzes patient data, assists with development and maintenance of care plans, and evaluates outcomes of interventions indicated by the multi-disciplinary care plan. Documents and communicates these interventions and outcomes per professional and organizational standards. Delegates tasks to other licensed and unlicensed care providers as appropriate. Assures compliance with regulatory body standards (including Joint Commission and PCMH).

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking
• Utilizes assessment skills to evaluate patient needs and formulate a plan of care, as part of the multi-disciplinary care team. Revises outcomes and interventions based on results of ongoing evaluation, collaborating with both the patient and members of the care team.
• Facilitates individual or group nursing visits with patients to address chronic illnesses, provides education about management and treatment of disease as needed.
• Identifies patients at risk for poor outcomes and those who may require more intensive services; provides additional outreach and frequent follow up (by phone and in-person) to this population.
• Provides Complex Case Management, including chronic disease case management, critical diagnosis care coordination, transition care management, high risk clinical tracking, complex medication management and system utilization to appropriate patients.
• Provides medication reconciliation and adherence counseling, while assessing patient knowledge and barriers to adherence and self care.
• Triages patients during walk-in/same day clinic.

Teamwork
• Collaborates with multi-disciplinary team to address both physical and psychological aspects of health to provide care for the whole patient.
• Works along with the Transition of Care Team to ensure safe and effective transitions of care.
• Collaborates with provider during appointments or in nursing visit for education on health promotion, disease prevention and/or management of disease.
• Flexible in scheduling to work the demands of the clinic schedule.

Patient Focus
• Assists patients in the development of self-management goals, evaluates ongoing status of goals along with other members of the interdisciplinary care team; coordinates follow-up as needed.
• Accesses appropriate resources inside and outside the organization to meet the needs of the caller/patient.
• Demonstrates awareness of cultural, ethnic, gender, sexual orientation and racial differences and their potential to impact patient outcomes.

SKILLS AND ABILITIES:
• Experience with documentation in an Electronic Medical Record
• Ability to work with computers in word processing, and database applications preferred.
• CPR certified by scheduled start date.
• Must be flexible and adapt to a changing environment.
• Able to prioritize competing responsibilities
EDUCATION AND/OR EXPERIENCE:
• Required: Graduate from an Accredited School of Nursing; Current Maryland Nursing License
• Preferred: One year of nursing in an ambulatory or acute care setting; BSN
• Significant related experience with populations served may substitute for above requirement.