Ambulatory Complex Care Coordinator

Join Our Team as a Registered Nurse! At TriHealth, we are driven by a shared commitment to excellence and innovation in healthcare. We believe that every test, analysis, and result plays a vital role in our mission to provide the highest standard of care to our patients. Join us in our mission to advance healthcare and improve lives. Apply today and be part of a team that is passionate about making a difference. We offer career growth opportunities and a comprehensive benefits package. Location: Partial remote Work Schedule: Full-Time (80 hours bi-weekly) Day Shift No weekend or holiday rotation Incentives & Benefits: Medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. Job Requirements Associate's degree or diploma in Nursing RN, Registered Nurse Progressive experience as an RN in a hospital, ambulatory, or home health setting Care management experience is preferred Strong oral and written communication skills and strong customer service skills with phone etiquette Collaborates well with the interdisciplinary team Proficient computer skills Epic experience is strongly preferred 2-3 years experience in Clinical Nursing, Hospital nursing 2-3 years experience in Clinical Nursing, Care Management, Home Care Job Overview The goal of Ambulatory Complex Care Management is to help patients reduce ED and inpatient admissions and avoid re‑admissions through longitudinal care management interventions that increase patient self‑management activities of chronic diseases, thereby improving quality of life. The Ambulatory Complex Care Manager supports the TriHealth Primary Care Physician practices utilizing clinical nursing skills to provide care management and make transition of care calls to value‑based patients discharged from inpatient and emergency hospital settings. Job Responsibilities Maintains patient panels, completes assigned outreach at scheduled intervals, and manages using evidence‑based care such as Standards of Practice for Case Management and NCQA Standards for Care Management. Utilizes clinical and claims reports, discharge reports, predictive modeling reports to identify patients for enrollment into the program. Ensures enrolled patients have documented advanced care planning discussions; provides resources and consults for assistance with ACP as needed; RN Care Managers provide education on ACP and encourage completion. Collaborates with the interdisciplinary team and Primary Care Providers, and communicates with enrolled patients consistently, documenting in the EMR with smart phrases. Enrolls targeted patients into the TOC program, makes scheduled outreach calls, schedules PCP follow‑up appointments, and refers patients to CCM consistently; follows NCQA guidelines and policies. Completes all required educational courses and attends at least 75% of departmental meetings, daily huddles, and scheduled meetings on calendar. #J-18808-Ljbffr TriHealth