Job Summary: The Ambulatory RN Care provides a full range of care management within the Patient Centered Medical Home Model (PCMH) to patients with both moderate and complex care needs throughout the A.O. Fox Physician Practices. The RN promotes discharge planning, continuity of care and patient advocacy throughout the Network, across all settings and levels of care. This work will include coordinated efforts involving acute, sub-acute, rehab, specialty, ED, community and other care areas as needed by developing and maintaining an individualized, interdisciplinary plan of care in collaboration with the patient, family and health care team. In the PCMH model the RN Care Manager will utilize a team approach in providing care to the A.O. Fox Physician Practices patient population and all of its services. Care management duties performed will include, but are not limited to assisting the team in identifying high risk patients for hospitalization, preventive/chronic disease care needs, follow up calls, discharge calls, handle appropriate messages from patients, scheduled and walk in visits etc. and acting as a liaison and primary conduit for the transmission of information between practitioners and patients. Will also provide advocacy, information and referral services to patients and families to address their medical and psychosocial needs.
Education - Graduation from an accredited Professional Registered Nurse Baccalaureate program
Experience - At least three years relevant experience. Two years' experience working as a member of a multidisciplinary team.
Knowledge/Skills/Abilities - Experience in leadership role preferred. Excellent written and verbal communication skills. Ability to assess clinical management of patients through chart review, participating in case reviews, assessments based on measurable outcomes, protocols, and medical discussions. Ability to apply evidenced based utilization review criteria. Proficient in computer – use of Excel, Word, the Internet and Health Information Technology preferred.
Physical Requirements - Walking, standing, and sitting required throughout the shift. Must be able to identify and differentiate colors. Must be able to lift up to 35 lbs.
Licenses/Certifications - Current NYS licensure as a Registered Professional Nurse. Valid New York State Driver's license and ability to travel.
-Provides support and leadership to staff RN's and LPN's
-Assists in developing and maintaining processes and assures competency for all staff providing care coordination services.
-Clinical and Technical Responsibilities: Provides Care Coordination services as appropriate throughout the life span at the A.O. Fox Practice(s) assigned.
-Responsibilities for Relationships, Collaboration and Teamwork: Collaborates with other health care team members in providing patient-centered care.
-Responsibility for Information: Offers and receives feedback on own performance and the quality of patient care and services delivered.
-Performs similar or related duties as requested or directed