Title:   Ambulatory Care RN Population Health/Chronic Care Manager

FLSA Category: Exempt

Reports To:      Ambulatory Care Nurse Manager

Date Issued:    September 2025

Date Revised:  October 2025                  

Job Summary: 

The Ambulatory Care RN Population Health/ Chronic Care Manager plays a essential role in improving patient outcomes, reducing hospital readmissions, and advancing preventive care through strategic care coordination and remote patient monitoring. This position supports key initiatives such as chronic care management and the Patient-Centered Medical Home (PCMH), while serving as a clinical resource for safe, efficient, and responsive care delivery.

Essential Job Functions:

1. Utilizes the nursing process to provide care management services to identify at-risk patients by supporting patient self-management of disease and behavior modification interventions.
2. Understands PCMH concepts and supports PCMH initiatives related to care management.
3. Maintains the volume of care management patients and care plans needed to meet PCMH requirements. 
4. Conducts patient education classes related to Diabetes Prevention, Diabetes Self- Management, and Obesity.
5. Manage and coordinate care for patients with chronic diseases and contribute to population health initiatives.
6. Monitor avoidable ER visits for each MCO and reach out to patients to determine reason for ER visit. Provide patient education on best way to utilize medical services.
7. Assist coordination of post discharge follow up appointments and needed medication and supplies.
8. Coach patients and family in follow-up to chronic health conditions and self-management strategies presented during hospitalization and planned clinic/health care provider visits.
9. Assist the Population Health Manager in identifying and mitigating gaps in care.
10. Educate nonadherent patients on the importance of closing care gaps and monitor patients for compliance.
11. Build and maintain positive working relationships with the patients, family members, providers, case managers and other health agency representatives
12. Continuously expand knowledge and understanding of community resources, services, and programs
13. Provides triage service in person or over the telephone
14. Provides health teaching and counseling to patients and families.  This may include communication test results, medication changes, etc.
15. Provides direct nursing care to patients, including performing assessments, nursing procedures (including injections), and assistance with procedures.
16. Offer medication reconciliation and adherence counseling while assessing patient knowledge and addressing barriers to adherence and self-care.
17. Assesses patient requests for same day services and works with Providers and Center Manager to ensure that patient needs are addressed appropriately.
18. Expedites patients flow through the implementation of standing orders or policies for medication refills, referrals, and immunizations.  Ensures that clinical medical assistants are familiar with standing order protocols and follow them appropriately. 
19. Participates in the immunizations process, including inventory and record keeping.  Ensures that vaccines are stored properly.  Oversee immunization administration process and educate staff regarding proper technique and current recommendations. Has knowledge of the Vaccines For Children program and assists with compliance. 
20. Oversees laboratory services, including review of quality control, oversight of inventory and record keeping.  Ensures that supplies are stored properly.   Supervises specimen collection process and in-house testing and educates staff regarding proper technique and current recommendations.
21. Participates in the maintenance of medication and medical supply inventory, including monthly expiration process. 
22. Provides clinical training to medical assistants and supervises competency evaluations as directed by the Ambulatory Care Nurse Manager.
23. Demonstrates proficiency in the use of the EMR and serves as a clinical resource.
24. Completes all other duties as assigned.

Nonessential Functions:

1. Participates in team/staff meetings; attends in service meetings and applicable workshops.  
2. Performs other duties as assigned.

Core Values: Quality Respect Teamwork Equity Integrity Passion Love

Minimum Qualifications

1. Current Registered Nursing License in the State of Maryland required.
2. Bachelor’s degree in Nursing or Associate’s Degree in Nursing
3. Experience with Care Management preferred
4. Current Cardiopulmonary Resuscitation Certificate (CPR)
5. Bilingual is a plus!
6. Pediatric experience is a plus!

Experience
 3-4 years Nursing experience in dealing with chronic disease management and population health.
 

Substitutions -None

Core Competencies Needed

Problem Solving – Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully, develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.

Communication Skills - Listen and verbally to solve problems and provide information and direction, ensuring the experience is a positive one. Record issues and resolutions to maintain accurate records and data for further analysis by management. 

Analytical Skills - The ability to tackle a problem by using a logical, systematic, sequential approach. Possess creative thinking, learning, systems thinking and problem solving. Must be effective at defining and solving problems to ensure that the real, underlying challenge is understood and that solutions actually address it.

Healthcare Systems - Knowledge of healthcare and medical terminology.

Risk Management/Compliance - Confidentiality principles and laws, maintain compliance with government contractual mandates.

Work Environment

This job operates in an outpatient office environment.

Physical and Mental Demands

1. Ability to cope with stress.
2. The person in this position needs to occasionally move about inside the center
3. Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
4. The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.
5. Must be able to lift or assist moving a patient weighing more than 50 pounds in the event of emergency.
6. Performs with frequent interruption or distractions.
7. Adjust priorities quickly as circumstances dictate.
8. Cognitive ability to analyze, count, summarize and synthesize information from multiple sources. 

Language Skills

Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization.

Travel

Must be able to drive between Greater Baden Medical Services, Inc. locations.