(Archived) Ambulatory Care Manager

Job Summary

Job Description

Minimum Qualifications

Education: Registered Nurse (RN) or Social Worker (LMSW)

Licenses/Certifications: Registered Nurse (RN) or Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) with active license in the state of Texas

Experience / Knowledge / Skills:

• Experience in care/case management, chronic disease management or population health preferred
• At least two (2) years of experience in care coordination and planning or other related area
• Experience working in interdisciplinary teams
• Excellent computer skills
• Effective oral and written communication skills
• Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.

Principal Accountabilities

• Provides primary care management interventions to identified members enrolled in the Health Management programs.
• In conjunction with payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination.
• Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.
• Provides proactive outreach to members to include telephonic, internet, or face-to-face encounters.
• Works cohesively with other health management disciplines to assist members in problem-solving potential issues related to financial and psychological barriers, as well as problems with the overall system of care.
• Increases continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.
• Manages effective transitions in care by facilitating warm hand-offs and closure of gaps in care.
• Promotes timely access to appropriate care and promote effective and efficient utilization of clinical resources.
• Promotes adherence to an established plan of care.
• Increases utilization of primary care services within an established network.
• Reduces emergency room utilization and hospital readmissions via a comprehensive approach.
• Increases patients’ ability for self-management and shared decision-making.
• Increases comprehension and health literacy through appropriate education.
• Provides medication management, including comprehensive medication review and make recommendations to primary care provider for medication changes based on evidence-based protocols.
• Provides chronic disease and self-management education and support.
• Connects patients to relevant community resources necessary to support health and well-being.
• Coordinates warm hand-off to member’s primary care provider upon successful completion of the program.
• Directs and participates in the development and implementation of member care policies and protocols in order to provide advice and guidance in handling special cases or member needs.
• Makes referrals to other Health Management team members as necessary to promote effective care coordination services.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Other duties as assigned.