Job Description:

This position works onsite at the primary care clinic in partnership with the practice staff and healthcare providers.

The Ambulatory Case Manager is a dedicated position responsible for case management of the Baptist Health patients attributed to value-based contracts and Baptist Health Care Partners attributed patients, which includes patients in the clinically integrated network and accountable care organization.

The Ambulatory Case Manager is responsible for engaging patients identified for case management services, developing a personalized plan of care, ensuring coordination of services, and managing individualized clinical and financial outcomes. The Practice-Dedicated Ambulatory Case Manager complies with regulatory requirements for chronic care management (CCM) billing for consented patients and offers other care management services for patients not eligible for CCM. This position collaborates with the practice staff and providers on care coordination, care planning, and health prevention.

The Ambulatory Case Manager facilitates health and disease patient education, supports patient self-management of disease, identifies issues and barriers to care, ensures patient meets heath maintenance requirements, coordinates continuity of patient care with external healthcare organizations and facilities, and with patients and families following utilization of services in various healthcare settings.

Essential Job Functions:

• Outreaches to patients and families following utilization of services in various healthcare settings to facilitate health and disease patient education, support patient self-management of disease, and ensure patient meets health maintenance requirements

• Management of patients with multiple co-morbidities or high risk for readmission to a hospital setting

• Evaluates clinical care, utilization of resources, and patient outcomes through ensuring patient participation in preventative care

• Develops collaborative relationships with Baptist Health affiliated and non-affiliated facilities, providers and care management teams to improve patient education, care coordination, case management, and clinical outcomes

• Coordinates continuity of patient care with all healthcare providers

• Provide case management support for other populations, upon request and if necessary

Minimum Requirements:

• Bachelor’s degree in Nursing (BSN) – applicable to new hires

• Certification in Case Management required within 2 years of date of hire or transition to value-based care

• At least five years of direct care nursing experience required

• At least 2 years ambulatory case management experience preferred

If you would like to be part of a growing family focused on supporting clinical excellence, teamwork and innovation, we urge you to apply now!

Employees will be expected to comply with Baptist Health’s infectious disease and vaccination policies, which include but may not be limited to compliance with BHS’ mandatory vaccination policies for influenza and COVID unless reasonable accommodations are needed under applicable law

Baptist Health is an Equal Employment Opportunity employer.