Job Overview:

The goal of Ambulatory Complex Care Management is to help patients reduce ED and inpatient admissions and avoid re-admissions through longitudinal care management interventions that increase patient self-management activities of chronic diseases thereby improving quality of life. The Ambulatory Complex Care Manager supports the TriHealth Primary Care Physician practices utilizing clinical nursing skills to provide care management and make transition of care calls to value based patients discharged from inpatient and emergency hospital settings. 

Job Requirements:

Associate's degree or diploma in Nursing 
RN, Registered Nurse
Progressive experience as a RN in a hospital, ambulatory or home health setting 
Care management experience is preferred 
Strong oral and written communication skills as well as strong customer service skills with phone etiquette Collaborates well with the interdisciplinary team Proficient computer skills 
Epic experience is strongly preferred
2-3 years experience Clinical Nursing Hospital nursing
2-3 years experience Clinical Nursing Care Management, Home Care

Job Responsibilities:

Maintains their panel of patients , completing assigned outreaches at the intervals they are due, and manages using evidence-based care such as Standards of Practice for Case Management, NCQA Standards for Care Management and program description. Utilizes both clinical and claims reports, discharge reports, predictive modeling reports to identify patients that would benefit from enrollment into the programs.
Ensures enrolled patients have a documented attempt for advanced care planning discussion, and this is documented in the EMR. Appropriate resources are sent to the patients and consults are made for assistance with ACP as needed. RN Care Managers provide education to patients and their families on the importance of ACP and encourage them to complete these documents and provide copies for the EMR. The Care Manager has attended MOLST training.
Collaborates with the interdisciplinary team and Primary Care Providers consistently and professionally. Communicates with their enrolled patients on a consistent bases and this is documented in the EMR in a standard way utilizing smart phrases.
TOC: Enrolls a large population of targeted patients with specific insurance contracts into the TOC program, makes scheduled outreach calls and schedules PCP follow-up appointments for these patients within specified timeframe thereby reducing re-admissions. Refers patients to CCM on a consistent basis. CCM: Enrolls patients, creates care plans, makes monthly follow-up calls and dis-enrolls patients once patients meet goals and/or before target date. Follows NCQA guidelines, policies and procedures, and program description. RN's make appropriate referrals and document using standardized smart phrases.
Completes all department assigned and mandatory education and attends at least 75% of the monthly department meetings. Attends daily huddles, has their camera on when required, is available and active on web ex and e-mail throughout the working day, is responsive to calendar invitations and attends scheduled meetings on their calendar on a consistent basis.

Other Job-Related Information:

Working Conditions:

Climbing - Occasionally
Concentrating - Frequently
Continuous Learning - Frequently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Rarely
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Frequently
Sitting - Frequently
Standing - Occasionally
Stooping - Rarely
Talking - Consistently
Thinking/Reasoning - Frequently
Use of Hands - Frequently
Color Vision - Frequently
Visual Acuity: Far - Occasionally
Visual Acuity: Near - Consistently
Walking - Occasionally

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service 
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community