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Eastside Health Network is currently hiring for the following positions! Please review the job description and follow the link to apply for one of these exciting opportunities

RN- Ambulatory Care Manager

Responsible for managing patient populations with chronic illness and/or multiple co-morbidities. 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, this role will assist patients in gaining self-efficacy/management skills to achieve optimum functional health status and quality of life.

Primary Duties:

  • 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
  • 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
  • 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 
  • 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.

To find out more about position, follow link: