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Ambulatory Care Manager

Requisition R023843 Market Cincinnati, OH Department Care Coordination - Population Health Service Organization Shift Schedule Full-time

Thank you for considering a career at Mercy Health!

This is what we were meant to do - Together!

The RN Ambulatory Care Coordinator’s primary responsibility is to oversee care coordination of Population Health patients for the primary care practice.  This includes assessment, developing and monitoring plan of care in collaboration with Primary Care Provider and care team.  It also includes identifying the high-acuity patient population and working to ensure care coordination for this patient population.  The position may involve some patient triage.  The overall goal of the role is to assist patients to progress to successful self-management of chronic health conditions, to assist in removing barriers to adherence of prescribed plan of care, and to reduce unnecessary admissions and/or ED utilization. The RN Ambulatory Care Coordinator will be collaborate with Primary Care providers, PCP office Care Team, Practice Manager, community providers, as well as Care Transition and Acute Care Case Management teams, to best serve the needs of the patient panel and the primary care teams.  The Nurse Coordinator will be responsible for collaborating with patients, providers and caregivers in developing a plan of care, documentation of aspects of Ambulatory Care Coordination (ACC) patient care, reviewing and utilizing appropriate patient care reports, and communication of ACC program aspects with primary care providers served. 

• Collaborating with patient, Primary Care provider and other members of the care team in developing and monitoring a plan of care
o Working with patient and patient’s care team to coordinate change readiness, needs, assessment, and develop an individualized plan of care.
o Assisting patients in setting SMART goals for self-management.
o Educating the patient about self-management tasks, including but not limited to self-monitoring and problem solving so the patient can gain confidence and greater control of their health status.
o Collaborating with the patient, Primary Care provider, and other care team members in assessing the patient’s progress toward individual healthcare goals.
o Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments and communicating these to the Primary Care provider and other care team members.
o Overseeing the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
o Refers patient to appropriate internal and community based resources based on need. 
o Coordinating referral to and communication with specialists as needed.  
o Collaborating with payer case managers for additional services when appropriate.
o Anticipating the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.

• Collaboration with Care Transitions Team to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physician, or by another healthcare provider.
o Support post discharge care of patient and assess understanding of post discharge care instructions.
o Assess medication adherence.
o Facilitate post-discharge follow up appointments as appropriate.
o Facilitate post-discharge transitions from Skilled Nursing facilities.

• Providing telephone advice per protocol, handling urgent calls and emergent calls.

• Maintains accurate and consistent documentation using the prescribed tools within the electronic health record to ensure use of searchable and reportable fields.

• Collaborates effectively as a care team member
o Collaborates with Primary Care provider to identify at risk members utilizing multiple available tools.
o Collaborates with the Primary Care provider and care team members by sharing community resources available to patients and maintaining collegial relationships with the entities used most frequently.
o Establish communication processes with ACC team, Primary Care providers served and care team members including but not limited to regular cadence of collaborative meetings, attendance at team meetings and huddles, and appropriate routing of documentation.
o Collaborates with ACC leader to identify outcome measures, prepare and analyze outcomes reports, and progress toward program goals as directed.

Minimum years and type of experience:

  • Three (3) years clinical practice experience with demonstrated critical thinking ability.
  • The ideal candidate will have well rounded clinical experiences including work in acute and/or outpatient settings.
  • Experience with electronic medical records and personal computer skills.

Other knowledge, skills, and abilities:

Experience with clinical pathways, data analysis, and health care operations.
Understanding and/or experience in coaching and motivational interviewing.

Mercy Health is an equal opportunity employer.

We’ll also reward your hard work with:

  • Great health, dental and vision plans
  • Prescription drug coverage
  • Flexible spending accounts
  • Life insurance w/AD&D
  • An employer-matched 403(b) for those who qualify.
  • Paid time off
  • Tuition reimbursement
  • And a lot more

Scheduled Weekly Hours:


Work Shift:


Care Coordination

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you’d like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, which is an Affirmative Action and Equal Opportunity Employer, please email If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at

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Amanda M., CRNP

Nursing is one of the most trusted professions in the world, and it’s because of who we are and how we care about patients.

Amanda M. CRNP
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