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By being hired into one of our Nursing jobs at EvergreenHealth, you’ll be a key member of the EvergreenHealth team. Professionals in Nursing careers come from a variety of backgrounds, bringing an assortment of knowledge and skills to every area of our business. Please click on your desired Nursing job below to learn more about the exact qualifications. A Nursing career at EvergreenHealth may be waiting for you!

Ambulatory Care Manager RN - Eastside Health Network

Job Title Ambulatory Care Manager RN - Eastside Health Network Req 30597 Department Eastside Health Network Date posted 06/26/2019 City Kirkland State WA Country US Shift Day Hours 40
Job Description

EvergreenHealth is seeking an experienced Ambulatory Care Manager to join the well -established Eastside Health Network Team. The Ambulatory Care Manager is responsible for managing patient populations with chronic illness and/or multiple co-rmorbidities. This RN works in coordination with multiple PCPs and serves as the central link to an identified population of patients. Through skilled assessment, education, collaboration and coordination of healthcare and community resources, assists patients to gain self-efficacy/management skills, achieve optimum functional health status, and quality of life. The Ambulatory Care Manager assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes.

Primary Duties:

1. Provides leadership and continuity of care guidance and support for patients with chronic diseases and/or complex disease states as they receive care throughout the care continuum. Uses knowledge of illness, diagnoses and treatments in comprehensive, holistic assessments of patients. Performs patient teaching, patient self-management/self-efficacy coaching and planned care management. Ensures coordination for specialty and other handoffs as necessary.

2. Utilizes appropriate resources to gather data and assess patient care needs; makes ongoing assessments of the following domains: physio-biological, cognitive/ emotional, spiritual and social, managing life with chronic disease; identifies problems that could lead to an emergency/crisis situation and takes appropriate action to de-escalate; identifies the need for and coordinates specialists/ consultants; communicates assessment data to appropriate persons; assesses learning needs of patient/significant others; documents assessment data according to clinic standards.

3. Plans for and manages a panel of patients with chronic/complex disease(s); plans interventions appropriate to patients' medical and nursing diagnoses, age, abilities and resources; establishes and implements patient directed learning and disease self-management plan for patient/significant others; documents planning process according to organizational standards

4. Provides teaching to patients/families related to patient's diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals with a focus on a patient self-management; documents each element of care per organizational and unit standards.

5. Accountable for following the guidelines for attendance, punctuality and overall dependability. Accountable for effective performance and follow-through of all assigned responsibilities and for completing responsibilities within designated (or agreed upon) timeframes. Completes responsibilities in a manner consistent with organizational policy, goals and values.

6. Responsible for the "Accountabilities" associated with this position in support of the organization.

7. Performs other duties as assigned.


·Must utilize one or more Cerner applications to deliver and track patient care.

·Knowledge and training to care for all age groups, including neonatal, pediatric, adult and geriatric.

·Proficient in the use of EMR system

·Able to access patient information/x-ray results and schedule patient appointment in the EMR systems independently

·Use VOIP telephone system effectively.

·Ability to conduct the nursing process over the phone, effectively communicating and assessing patient needs telephonically.

·Knowledge of care management and patient self-management principles, evaluating patient outcomes with data, payor reimbursement and care delivery systems across the continuum.

License, Certification, Education or Experience:

REQUIRED for the position:

· Bachelors of Science degree in Nursing

· Licensed as a Registered Nurse in the State of Washington

· Currently certified in BLS.

· Two years of work experience in a Registered Nurse role

· Excellent patient assessment skills, ability to work collaboratively in team setting, current working knowledge of electronic medical records.

· Ability to manage a variety of concurrent programs and projects effectively while Utilizing time, equipment and supplies appropriately.

DESIRED for the position:

·Experience with complex patients with advanced, chronic and/or behavioral health illnesses in an ambulatory setting.

·Experience with case management of complex patients

·Certification in diabetes education (CDE).

·Certification in Case Management.

Apply here:

Are you a current EVERGREENHEALTH employee? Yes