Ambulatory Chronic Care Manager (RN)

Yale New Haven Health•New Haven, CT

7d•Remote

About The Position

The Ambulatory Chronic Care Manager (RN) is part of the enterprise Ambulatory Care Management team and is accountable for improving health outcomes for all patients, with particular focus on patients in value-based or risk contracts. The role works as part of a multidisciplinary team under the direction of Ambulatory Care Management leadership. The manager performs nursing assessments, evaluations, and screenings, and develops action plans to address gaps in clinical care. Care management activities include managing care transitions, medication reconciliation and review, providing patient-centered education about acute or chronic illnesses, evaluating social determinants and barriers to care, adhering to quality metrics, facilitating communication among providers, and advocating for patients, families, and support systems. The position is primarily remote, with travel to onsite practice locations as requested by management. The role also requires attending initial onsite orientation and onboarding and monthly onsite training, and complying with organizational remote-worksite standards.

Requirements

Minimum of a baccalaureate degree in a clinically related field.
Connecticut RN licensure required.
At least 3 years of combined clinical experience in direct patient care and care coordination or case management in an acute, community, or post-acute provider or health plan.
Motivational interviewing skills.
Excellent verbal and written communication skills.
Excellent organizational skills and ability to manage multiple priorities.
Ability to work independently with minimal supervision.
Ability to function as an integral team member and flexibility in sharing responsibilities.
Working knowledge of computers and basic software applications, such as word processing, databases, and spreadsheets.

Nice To Haves

Certified Case Manager (CCM) or accredited equivalent certification preferred.
Validated translation capability preferred.

Responsibilities

Outreach to and enroll patients in chronic care management programs, establish therapeutic relationships, and manage patient engagement throughout the program.
Participate in interdisciplinary team rounds to address utilization, resources, and progression-of-care issues.
Assist in developing and implementing improvement plans to address care issues.
Apply evidence-based practices and clinical practice guidelines to care plans and patient interventions.
Perform other duties as required or requested.
Perform nursing assessments, evaluations, and screenings and develop action plans to address gaps in clinical care.
Manage care transitions and perform medication reconciliation and review.
Provide patient-centered education related to acute or chronic illnesses.
Evaluate social determinants and barriers that affect care management.
Adhere to quality metrics, facilitate communication among providers, and advocate for patients, families, and support systems.