Ambulatory Nurse Case Manager / Patient Care Coordinators

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued.

Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve.

Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview

The Nurse Case Manager serves the patient population at the organization and is a core team member to the continuity of patient care.

The Nurse Case Manager acts as an expanded health care role to collaborate across the continuum with the primary care team, specialty care team, inpatient case management, social work, members of community health care teams, and patients/families to ensure the delivery of quality, cost-effective health care services.

Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status.

Essential Functions

• Responsible for developing a comprehensive, individualized plan of care and targeted interventions.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Continually monitors patient/family response to plan of care and revises the care plan as indicated.
• Maintains comprehensive medical record documentation on the appropriate information systems and databases using required documentation and billing guidelines.
• Utilize electronic health record (EHR) activities to manage preventative care for patients.
• Proactively reach out to patients most in need of care by utilizing EHR reporting tools.
• Manage the care of high risk patients using EMR patient outreach tools, which may include but not limited to: completing appropriate assessments, creating and tracking patient goals, and managing health maintenance
• Assist in the development of adequate workflows to ensure patient care needs are met.
• Collaborates with Providers, patients, families, and members of health care teams across a continuum of care settings and the community.
• Fosters a team approach and includes patient/family as active members of the team.
• Takes the lead in ensuring the continuity of care which extends beyond the clinic boundaries.
• Serves as liaison to acute care hospitals, specialists, post-acute care services and community agencies.
• Provides follow-up with patient/family when patient transitions from one setting to another.
• Completes timely post-hospital follow-up activities including review of discharge instructions, condition specific education, coordination of care, and assists in problem solving barriers.
• Identifies targeted, rising risk and high risk populations within clinic site(s) per Provider referral, risk stratification, registries, and/or patient lists.
• Assesses the health care, educational, and psychosocial needs of the patient/family.
• Uses standardized assessment tools such as Nurse Case Management assessments and health risk assessments.
• Develops individualized patient/family education plans. Instructs and counsels patient/family regarding acute/chronic illnesses, the use of prescribed treatments and medications, care coordination.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care and integrate health promotion into their lifestyle.
• Works with clinic and leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management.

Education Qualifications

• Bachelor's Degree from an accredited college or university in nursing required.

Experience Qualifications

• Minimum 5 years in nursing required.
• Experience in a pediatric health care setting preferred.

Skills and Abilities

• Demonstrated written and verbal communication skills. (High proficiency)
• Ability to apply the nursing process to acute patient care to achieve outcomes. (High proficiency)
• Current knowledge of the healthcare environment, including community resources and financial systems. (High proficiency)
• Working knowledge of basic computer programs such as word, excel. Knowledge of smart phone use. (High proficiency)

Licenses and Certifications

• Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required.
• Basic Life Support from the American Heart Association Upon Hire Required.
• Certified Pediatric Nurse Preferred.
• Nursing Case Management Board Certification certification from a nationally recognized case management organization Preferred

Children’s is the very best for kids and the very best for your career!

At Children’s, we put YOU first so together, we can improve the life of every child!