Ambulatory Chronic Care Manager (RN)

Ambulatory Chronic Care Manager (RN)

The Ambulatory Chronic Care Manager will help improve health outcomes for patients living with chronic conditions through personalized care coordination, clinical assessment, and ongoing patient engagement. Working as part of a multidisciplinary ambulatory care management team, you will identify gaps in care, develop individualized action plans, and support patients throughout their healthcare journeys. The role focuses on improving care quality, coordinating transitions between healthcare settings, and helping patients navigate clinical, medication-related, and social barriers. You will collaborate with providers and care teams to promote evidence-based interventions, improve patient engagement, and support quality performance goals. This primarily remote position offers the opportunity to make a meaningful difference in patient well-being while contributing to coordinated, value-based healthcare delivery. Occasional travel to clinical practice locations, onsite onboarding, and monthly training sessions are required.

Accountabilities

• Conduct nursing assessments, evaluations, and screenings to identify patient needs, clinical risks, and gaps in care.
• Reach out to eligible patients and enroll them in chronic care management programs, establishing therapeutic relationships and maintaining engagement throughout the program.
• Develop and implement individualized care plans and action steps to address clinical needs, improve outcomes, and close gaps in care.
• Apply principles of care management, complex disease management, care transitions, post-acute care planning, and community-based support.
• Coordinate transitions between healthcare settings and support continuity of care through effective communication, follow-up, and care planning.
• Perform medication reconciliation and medication reviews to help identify discrepancies and support safe, effective treatment.
• Provide patient-centered education regarding acute and chronic conditions, treatment plans, medication management, and self-care strategies.
• Assess social determinants of health and identify barriers that may affect access to care, adherence to treatment, or successful care management.
• Collaborate with multidisciplinary healthcare professionals during team rounds to address resource utilization, care progression, and patient management challenges.
• Contribute to the development and implementation of improvement plans that address care coordination issues and support appropriate resource use.
• Apply evidence-based practices and clinical guidelines to patient interventions and care plans.
• Monitor adherence to clinical standards, quality measures, and expected outcomes, helping improve performance in value-based and risk-based care arrangements.
• Advocate for patients, families, and support systems while facilitating communication among providers and other stakeholders.
• Perform additional duties as needed to support the goals of the ambulatory care management team.

Requirements

• Bachelor's degree in a clinically related field.
• Active Registered Nurse (RN) license in Connecticut.
• At least three years of combined clinical experience in direct patient care and care coordination or case management within an acute-care, community, post-acute care provider, or health plan setting.
• Certified Case Manager (CCM) credential or an equivalent accredited certification preferred.
• Strong understanding of chronic disease management, care coordination, care transitions, post-acute care options, and community-based care standards.
• Ability to apply evidence-based clinical practices and guidelines to assessments, care plans, and patient interventions.
• Demonstrated motivational interviewing skills and the ability to engage patients in their care, encourage participation, and support behavior change.
• Excellent verbal and written communication skills, including the ability to coordinate effectively with patients, families, providers, and multidisciplinary teams.
• Strong organizational and time-management skills, with the ability to manage multiple priorities and maintain accurate documentation.
• Ability to work independently with minimal supervision while contributing effectively to a collaborative team environment.
• Flexibility in sharing responsibilities and responding to changing patient and operational needs.
• Working knowledge of computers and standard software applications, including word processing, databases, and spreadsheets.
• Validated translation capabilities preferred.
• Spanish-speaking ability highly preferred.
• Ability to work primarily remotely while traveling to onsite practice locations when requested by management.
• Availability to attend initial onsite orientation and onboarding, as well as monthly onsite training sessions.
• Ability to comply with organizational remote-work requirements and applicable clinical and operational standards.

Benefits

• Hourly compensation: $37.00$83.23 USD per hour. Actual compensation depends on relevant experience, education, licensure, certifications, skills, specialty expertise, scheduled hours, work location, market conditions, and internal equity.
• Employment status: Full-time position with benefits eligibility.
• Work schedule: Day shift.
• Remote flexibility: Primarily remote work, with occasional travel to clinical practice locations and required onsite onboarding and monthly training.
• Healthcare coverage: Eligible employees may receive medical, dental, and vision insurance.
• Retirement benefits: Retirement savings benefits may be available, subject to applicable eligibility requirements and plan terms.
• Paid leave: Paid time off and leave benefits may be available, depending on eligibility and applicable policies.
• Education and professional growth: Potential access to tuition assistance and professional development opportunities.
• Additional protection and wellness benefits: Life and disability insurance and wellness programs may be included in the benefits package, subject to eligibility and plan terms.
• Meaningful clinical impact: An opportunity to improve chronic disease management, care coordination, patient engagement, and healthcare outcomes.