Registered Nurse - Ambulatory Care Management

Job Description
SUMMARY

THIS OPPORTUNITY IS ELIGIBLE FOR A SIGN-ON BONUS!

We provide a flexible work environment that allows for a greater level of independence - and with Rochester Regional Health there are opportunities for long-term career growth!

A registered nurse, working in collaboration with primary care providers and care team to identify and proactively manage the needs of patients with high risk or complex medical, behavioral health and/or psychosocial problems through practice, community and home based visits and telephonic support. The Care Manager develops and implements a care management plan based on patient goals, preferences and disease states to promote improved health care outcomes and quality of life. The care manager links patients to appropriate community resources, facilitates referral to appropriate care services, supports patient self-management, and communicates with providers in order to reduce barriers to improved health care outcomes. The Care Manager serves as an integral member of the primary care practice's care team, assesses patients for risk of adverse health outcomes, and measures the impact of care management interventions.

STATUS: Full-Time

LOCATION: Rochester General Hospital, Rochester, NY

DEPARTMENT: Ambulatory - Care Management

SCHEDULE: Monday - Friday, 40 Hours/Day Shift

ATTRIBUTES

• Associate's Degree in Nursing required with Care Management experience
  
• OR an Associate's Degree in Nursing and Bachelor's Degree in another discipline
  
• Bachelors in Nursing (BSN) preferred
  
• Clinical nursing experience with 3+ years of community health experience preferred
  
• Knowledge of community resources required
  

RESPONSIBILITIES

• Care Management. Identify High risk populations that meet eligibility criteria for complex care management services using standard analytics and referral resources. Monitor and analyze utilization of health care services including IP, ED and 30 day readmission visits with appropriate follow up. Develop an individualized, patient centered care management plan based on the patient's goals, strengths and barriers that promote improved health care outcomes and quality of life in collaboration with patient, family or care giver and other members of the health care team
  
• Transitional Care. Provide comprehensive transitional care involving coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge or skilled nursing facility admission and discharge
  
• Crisis Intervention. Provide crisis intervention planning addressing events such as emergency department visits or inpatient admissions or other crisis events to ensure planned crisis interventions are effective.
  

EDUCATION LICENSES/CERTIFICATIONS RN - Registered Nurse - New York State Education Department (NYSED); BLS - Basic Life Support - American Heart Association (AHA) Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran PHYSICAL REQUIREMENTS : M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.