Ambulatory Care Manager

Position Purpose:
Coordinates and manages care for the high and rising risk population through multiple care delivery systems,
supporting patient in self-management of their health.

Key Responsibilities:
Coordinate and manage care of high risk population
• Complete telephonic outreach and home visits as applicable based on patient acuity.
• Performs a comprehensive care management assessment of patient needs to ensure optimal health
outcomes.
• Develops a self-management action plan of care, coordinates services and navigates the patient
through the health care system with a goal of enabling the patient and family to effectively manage
their condition(s) and optimize outcomes.
• Coordinates effective transitions of care and effective handoffs to the next level of care across the
entire continuum.
• Collaborates with the patients care team including but not limited to hospital team, primary care
team, specialists, home care, SHCN clinical programs, and any others involved with patients care and
approved by the patient to ensure effective coordination of services and full understanding and
execution of the care plan.
• Maintains required medical documentation for care management activities in the system’s care
management module (electronic medical records), according to the standards of work.
• Follows standards of work and consistently maintains department established caseloads and
timeframes for case completion.
• Documents and reports all quality and patient safety events by recording and adhering to all of
Steward Health Care Network’s safety reporting guidelines.
• Performs other duties as assigned

Process Improvement:
• Evaluates processes, identifies problems, and proposes improvement strategies to enhance the
delivery of care for patients throughout continuum of care.
• Escalates any barriers to positive outcomes to supervisor and/or manager same day
• Participates in the refinement of and development of new standards of work.
• Maintains awareness of key performance indicators/metrics and manages caseload through
appropriate management of medical expenses. Coordinates interventions to prevent adverse events
such as ED visits, hospital admissions, and readmissions.
• Attend staff meetings and education offerings both in person and via teleconference as required

Education:
• Graduate of a state-approved school of nursing; Bachelors of Science in Nursing (BSN) preferred.
• Possess a current unrestricted RN license in the Commonwealth of Massachusetts and willing to obtain
in other states as needed.
• Must maintain Basic Life Support (BLS) certification.
• Certified Case Management (CCM) or CCM eligible strongly preferred.

Years of Experience:
• Minimum of 3-5 years’ relevant clinical nursing experience required.

Specialized Knowledge:
• Experience educating patients and families with self-management
• Creation and implementation of patient-centered care plans
• Utilization of motivational interviewing when engaging patients/families
• Knowledge of chronic disease management
• Understanding of Medicare and Medicaid regulations

About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.

Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.

For more information, visit steward.org