Children's National Hospital
Ambulatory Nurse Case Mgr
Children's National Hospital, Washington, District of Columbia, us, 20022
Overview
Ambulatory Nurse Case Manager role at Children's National Hospital. Responsibilities
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 patient progress on care goals, regularly interfacing with the care team and refining the care plan as indicated. Identifies barriers to attaining goals within the 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 effective, efficient services to meet the patient’s complex needs. Maintains care plans in coordination with practices/care delivery system and case management team members. Collaborates with the clinical care team as well as the case management care team to define interventions to meet the patient's 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 as applicable. Transitions of Care: Accepts and facilitates bi-directional care transition hand-offs to follow-up 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 supports a smooth transition from pediatric to adult care and providers. Documentation and Data Management: Documents patient consent, the plan of care, and reviews at designated intervals and updates as needed; shares with physician and patient caretaker. Leverages IT systems to capture data and submit claims for care management as needed. Monitors data reports and registries to identify 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: Includes organizational commitment, teamwork and communication, performance improvement, cost management, safety and related standards. Demonstrates collaborative and respectful behavior, supports a positive work environment, and communicates accurately and timely. Uses resources efficiently and promotes safety for patients, families, visitors and co-workers. Qualifications
Minimum Education: BSN (Required). Master's Degree (Preferred). Minimum Work Experience: 4 years nursing experience in case management, ambulatory nursing or home/community care (Required). Required Skills/Knowledge: Ability to critically think, apply logic to dynamic healthcare environments, superior verbal communication, strong business writing, and proficiency with Microsoft Office Excel, Access and PowerPoint. Required Licenses And Certifications: Registered Nurse in District of Columbia (Required). Licensed RN (Required). Functional Accountabilities: Certification in Case Management (Preferred); Ambulatory Case Management experience (desirable). Work Details
Primary Location: District of Columbia-Washington Work Location: CN Hospital (Main Campus) Job: Nursing Organization: Patient Services Position Status: Regular Shift: Day Work Schedule: 0830-1700 Job Posting: Sep 4, 2025 Salary Range: $82,347.20/yr - $137,238.40/yr
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Ambulatory Nurse Case Manager role at Children's National Hospital. Responsibilities
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 patient progress on care goals, regularly interfacing with the care team and refining the care plan as indicated. Identifies barriers to attaining goals within the 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 effective, efficient services to meet the patient’s complex needs. Maintains care plans in coordination with practices/care delivery system and case management team members. Collaborates with the clinical care team as well as the case management care team to define interventions to meet the patient's 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 as applicable. Transitions of Care: Accepts and facilitates bi-directional care transition hand-offs to follow-up 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 supports a smooth transition from pediatric to adult care and providers. Documentation and Data Management: Documents patient consent, the plan of care, and reviews at designated intervals and updates as needed; shares with physician and patient caretaker. Leverages IT systems to capture data and submit claims for care management as needed. Monitors data reports and registries to identify 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: Includes organizational commitment, teamwork and communication, performance improvement, cost management, safety and related standards. Demonstrates collaborative and respectful behavior, supports a positive work environment, and communicates accurately and timely. Uses resources efficiently and promotes safety for patients, families, visitors and co-workers. Qualifications
Minimum Education: BSN (Required). Master's Degree (Preferred). Minimum Work Experience: 4 years nursing experience in case management, ambulatory nursing or home/community care (Required). Required Skills/Knowledge: Ability to critically think, apply logic to dynamic healthcare environments, superior verbal communication, strong business writing, and proficiency with Microsoft Office Excel, Access and PowerPoint. Required Licenses And Certifications: Registered Nurse in District of Columbia (Required). Licensed RN (Required). Functional Accountabilities: Certification in Case Management (Preferred); Ambulatory Case Management experience (desirable). Work Details
Primary Location: District of Columbia-Washington Work Location: CN Hospital (Main Campus) Job: Nursing Organization: Patient Services Position Status: Regular Shift: Day Work Schedule: 0830-1700 Job Posting: Sep 4, 2025 Salary Range: $82,347.20/yr - $137,238.40/yr
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