Telephonic Nurse Care Manager

At AMC Health, we practice advanced virtual caregiving. Using a whole-person care approach, we go beyond simply monitoring patients to enhancing all aspects of their care, including medical health, mental health, health literacy, and health equity.

Our solution provides critical guidance at every step of the clinical care process - from enrolling patients to daily monitoring to timely interventions to help deliver the best possible outcomes Nurtured through an unparalleled trove of proprietary patient data, out platform's advanced machine learning models collect and analyze data in real time to optimize clinical workflows and efficiently stratify risk. We enable clinicians to be clinicians maximizing their medical expertise - and help patients heal in the comfort of their home.

As a nurse care manager, you will be responsible for the telephonic management of patients with chronic conditions, including, but not limited to, CHF, COPD, Diabetes, Hypertension, etc. You will remotely assess patients to understand the status of their health problems, develop and implement nursing care plans, make referrals to appropriate resources and maintain the clinical chart.

Essential Job Function :

• Collaborate with the patient and their care team, both internally and externally
• Conduct assessments and evaluate biometric and IVR data with trend analysis
• Evaluate care through problem-solving, analyze trends and variances and participate in quality improvement efforts to enhance clinical outcomes
• Engage the patient in their care, utilizing Motivational Interviewing techniques to influence patient behavioral changes to increase the level of adherence with customized care
• Utilize the case management process to set priorities, plan, organize and implement interventions that are goal directed towards self-management and the transition to independent status
• Document accurately and comprehensively based on the standards of practice and current organization policies and positively and effectively participate in chart audit review process to maintain standards of documentation and care.
• Interact and communicate, telephonically, through video or other approved technologies, striving for continuity and efficiency as the patient is managed along the continuum of care
• Perform care management responsibilities per customer requirements
• Recognize urgent situations and escalate appropriately

Competencies Required for Position :

Experience / Education / Computer Proficiency Requirements :

Licensure and / or Certification Requirements :

Physical Demands & Work Environment :