Registered Nurse, Ambulatory Care Management

HealthPartners•Bloomington, MN

3d•$40 - $60•Hybrid

About The Position

The Ambulatory Care Management RN works with high-risk patients and is responsible for the assessment, reassessment, complex care planning and coordinating care and services including ongoing monitoring of an appropriate and effective person-centered care plan, patient education, and care management. This position acts as an advocate for the patient; practices cultural competence and addresses, assesses and plans for drivers of social health needs; effectively communicates with patients, families, and the interdisciplinary care team; prioritizes patient needs and responsibilities based on data and outcomes; and puts the patient at the center. Practices the Quadruple Aim of reducing unnecessary costs and services to drive efficient quality outcomes while addressing patient and team satisfaction. Works with value contracts to case find, screen, engage and enroll high risk patients and create a plan of care to mitigate identified risk areas to achieve health goals. Practices complex navigation to identify needed services, helps engage patients to use those services and mitigate barriers to achieve those services. Support patients telephonically as well as in clinic as part of a hybrid model. This is an ideal opportunity for creative, motivated, self-starters. Successful RNs in this role enjoy challenges, variety, autonomy, and have a passion for Value-Based Care.

Requirements

BS or BA in nursing from an accredited college or university.
Minimum of 5 years’ clinical experience
2 years’ care coordination/care management experience within the last 5 years.
Maintain a current Minnesota and Wisconsin registered nurse license, one of which must be current upon hire. The other state license must be obtained with 30 days of hire.

Nice To Haves

PHN, CCM

Responsibilities

Assessment, reassessment, complex care planning and coordinating care and services
Ongoing monitoring of an appropriate and effective person-centered care plan
Patient education and care management
Acts as an advocate for the patient
Practices cultural competence and addresses, assesses and plans for drivers of social health needs
Effectively communicates with patients, families, and the interdisciplinary care team
Prioritizes patient needs and responsibilities based on data and outcomes
Puts the patient at the center
Practices the Quadruple Aim of reducing unnecessary costs and services to drive efficient quality outcomes while addressing patient and team satisfaction
Works with value contracts to case find, screen, engage and enroll high risk patients and create a plan of care to mitigate identified risk areas to achieve health goals
Practices complex navigation to identify needed services, helps engage patients to use those services and mitigate barriers to achieve those services
Support patients telephonically as well as in clinic as part of a hybrid model