Children's National Medical Center
Ambulatory Nurse Case Mgr
Children's National Medical Center, Washington, District of Columbia, us, 20022
Overview
The Ambulatory Nurse Case Manager is responsible for comprehensively and actively managing the care management and coordination needs of payer defined and/or payer enrolled populations or patients who meet designated inclusion criteria. This includes activities such as assessments, formal Case Management care plan development, establishing goals and interventions, and monitoring/tracking. The Ambulatory Nurse Case Manager partners with physician practices and the care management team to address the clinical and care coordination needs of the patient, and works with payers and/or community resources to develop and facilitate effective, efficient care delivery options for identified at-risk patients across the care continuum. Qualifications
Minimum Education BSN (Required) Master's Degree (Preferred) Minimum Work Experience 4 years Nursing experience in case management, ambulatory nursing or community/homecare experience preferred (Required) Required Skills/Knowledge Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment. Requires superior verbal communication skills and service excellence approach with internal and external stakeholders. Must have strong business writing skills. Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point. Required Licenses and Certifications Registered Nurse in District of Columbia (Required) Licensed RN (Required) Certification in Case Management preferred (Preferred) Functional Accountabilities
Ambulatory Case Management Provides intensive case management and care coordination for higher risk sub-populations defined by federal and third party payers or through case finding and referrals that meet inclusion criteria Develops and documents comprehensive care plans with clinician and family identified goals Assesses and monitors patientacts progress on care goals, regularly interfacing with care team and refining the care plan as indicated Identifies barriers to attaining goals within care plan and mobilizes resources to mitigate barriers Supports family self-management and patient advocacy through education and communication Collaboration with Medical Home and Care Management Team
Coordinates and collaborates with physicians and other providers to facilitate provision of effective, efficient services to meet the patients complex needs Maintains care plans in coordination with practices/care delivery system and case management team members Collaborates with clinical care team as well as case management care team to define interventions to meet the patients care management needs and any population health goals Delegates and supervises care management activities to non-nursing team members in accordance with the DC Nurse Practice Act. Provides or organizes relevant patient education and health coaching, condition-specific as applicable Transitions of Care
Accepts and facilitates bi-directional Care Transition hand-offs to follow-up of enrolled patients after ED visit, Urgent Care, Observation, Inpatient, SNF stay and transitions to adolescent and adult providers Works with payers, acute and post-acute care providers/care managers and/or community resources to develop and facilitate effective, efficient, sustainable care delivery options across settings. Communicates patient care plan and needs to new care teams as patient transitions to different care settings across the continuum. Guides and support a smooth transition from pediatric to adult care & providers Documentation and Data Management
Documents patient consent for case management and care coordination as required Documents the plan of care, reviews at designated intervals and updates as needed; shares with physician and patient caretaker Leverages IT systems to capture data; submit claims for care management as needed Monitors data reports and registries to case find patients in need of outreach and/or case management interventions and care coordination Reviews data outcomes for patient caseload to identify clinical, quality and/or financial metrics that require attention and intervention. Organizational Accountabilities
Organizational Accountabilities (Staff) Anticipate and respond to customer needs; follows up until needs are met Teamwork/Communication: Demonstrate collaborative and respectful behavior Partner with all team members to achieve goals Receptive to others' ideas and opinions Performance Improvement/Problem-solving: Contribute to a positive work environment Demonstrate flexibility and willingness to change Identify opportunities to improve clinical and administrative processes Make appropriate decisions, using sound judgment Cost Management/Financial Responsibility: Use resources efficiently Search for less costly ways of doing things Safety: Speak up when team members appear to exhibit unsafe behavior or performance Continuously validate and verify information needed for decision making or documentation Stop in the face of uncertainty and take time to resolve the situation Demonstrate accurate, clear and timely verbal and written communication Actively promote safety for patients, families, visitors and co-workers Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance Location
Primary Location : District of Columbia-Washington Work Locations : CN Hospital (Main Campus), 111 Michigan Avenue NW, Washington 20010 Job : Nursing Organization : Patient Services Position Status : R (Regular) - FT - Full-Time Shift : Day Work Schedule : 0830-1700 Job Posting : Sep 10, 2025, 2:46:46 PM Full-Time Salary Range : 82347.2 - 137238.4
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The Ambulatory Nurse Case Manager is responsible for comprehensively and actively managing the care management and coordination needs of payer defined and/or payer enrolled populations or patients who meet designated inclusion criteria. This includes activities such as assessments, formal Case Management care plan development, establishing goals and interventions, and monitoring/tracking. The Ambulatory Nurse Case Manager partners with physician practices and the care management team to address the clinical and care coordination needs of the patient, and works with payers and/or community resources to develop and facilitate effective, efficient care delivery options for identified at-risk patients across the care continuum. Qualifications
Minimum Education BSN (Required) Master's Degree (Preferred) Minimum Work Experience 4 years Nursing experience in case management, ambulatory nursing or community/homecare experience preferred (Required) Required Skills/Knowledge Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment. Requires superior verbal communication skills and service excellence approach with internal and external stakeholders. Must have strong business writing skills. Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point. Required Licenses and Certifications Registered Nurse in District of Columbia (Required) Licensed RN (Required) Certification in Case Management preferred (Preferred) Functional Accountabilities
Ambulatory Case Management Provides intensive case management and care coordination for higher risk sub-populations defined by federal and third party payers or through case finding and referrals that meet inclusion criteria Develops and documents comprehensive care plans with clinician and family identified goals Assesses and monitors patientacts progress on care goals, regularly interfacing with care team and refining the care plan as indicated Identifies barriers to attaining goals within care plan and mobilizes resources to mitigate barriers Supports family self-management and patient advocacy through education and communication Collaboration with Medical Home and Care Management Team
Coordinates and collaborates with physicians and other providers to facilitate provision of effective, efficient services to meet the patients complex needs Maintains care plans in coordination with practices/care delivery system and case management team members Collaborates with clinical care team as well as case management care team to define interventions to meet the patients care management needs and any population health goals Delegates and supervises care management activities to non-nursing team members in accordance with the DC Nurse Practice Act. Provides or organizes relevant patient education and health coaching, condition-specific as applicable Transitions of Care
Accepts and facilitates bi-directional Care Transition hand-offs to follow-up of enrolled patients after ED visit, Urgent Care, Observation, Inpatient, SNF stay and transitions to adolescent and adult providers Works with payers, acute and post-acute care providers/care managers and/or community resources to develop and facilitate effective, efficient, sustainable care delivery options across settings. Communicates patient care plan and needs to new care teams as patient transitions to different care settings across the continuum. Guides and support a smooth transition from pediatric to adult care & providers Documentation and Data Management
Documents patient consent for case management and care coordination as required Documents the plan of care, reviews at designated intervals and updates as needed; shares with physician and patient caretaker Leverages IT systems to capture data; submit claims for care management as needed Monitors data reports and registries to case find patients in need of outreach and/or case management interventions and care coordination Reviews data outcomes for patient caseload to identify clinical, quality and/or financial metrics that require attention and intervention. Organizational Accountabilities
Organizational Accountabilities (Staff) Anticipate and respond to customer needs; follows up until needs are met Teamwork/Communication: Demonstrate collaborative and respectful behavior Partner with all team members to achieve goals Receptive to others' ideas and opinions Performance Improvement/Problem-solving: Contribute to a positive work environment Demonstrate flexibility and willingness to change Identify opportunities to improve clinical and administrative processes Make appropriate decisions, using sound judgment Cost Management/Financial Responsibility: Use resources efficiently Search for less costly ways of doing things Safety: Speak up when team members appear to exhibit unsafe behavior or performance Continuously validate and verify information needed for decision making or documentation Stop in the face of uncertainty and take time to resolve the situation Demonstrate accurate, clear and timely verbal and written communication Actively promote safety for patients, families, visitors and co-workers Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance Location
Primary Location : District of Columbia-Washington Work Locations : CN Hospital (Main Campus), 111 Michigan Avenue NW, Washington 20010 Job : Nursing Organization : Patient Services Position Status : R (Regular) - FT - Full-Time Shift : Day Work Schedule : 0830-1700 Job Posting : Sep 10, 2025, 2:46:46 PM Full-Time Salary Range : 82347.2 - 137238.4
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