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Ambulatory Care Manager, Part Time

Position Summary: The Ambulatory Care Manager coordinates and manages care to meet multiple service needs of their population to overcome fragmentation of care and services. The objectives include assisting at risk beneficiaries with to coordinate crisis and behavioral health interventions, connection to social and community services, and follow up to improve patient outcomes and experience. Care management is an intermittent or continuous process. The Ambulatory Care Manager assesses individual's needs, develops individualized care plans, facilitates, implements, and coordinates health services, monitors and evaluates health services and documents interventions. Works collaboratively with the entire clinical team.
Maintains knowledge of applicable Federal, State, and local laws and regulations.
Demonstrates effective team behavior and supports colleagues in achieving objectives.
Identifies appropriate high risk, high cost beneficiaries to provide care coordination.
Completes initial, comprehensive health assessment of the physical, social, environmental, financial and functional state of the patient. Understands patient's health literacy level.
Identifies patient goals, both short term and long term
Develops and maintains care coordination plan that is consistent with patient's goals, understanding of disease and abilities with the goal of self-management whenever possible.
Plans interventions as needed to ensure the patient receives the most cost effective services and/or treatment in the most appropriate setting across the continuum.
Acts as a liaison between the beneficiary, physician and health plan. Maintains regular contact with patient and providers in active cases.
Reassesses beneficiaries care plan and resources at appropriate interval and pauses or closes a case based on guidelines. Increases contact when necessary in active cases.
Participates in addressing quality issues.
Identifies and maintains knowledge of community resources.
Assists in educating in his/her role to physicians and other clinicians
Demonstrates understanding of fiscal and legal issues which arise.
Conducts and documents telephonic or on-site care plans and maintains task list. Completes tasks timely.
Other duties as assigned.


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