Ambulatory Care Manager

Practice Area healthcare/nursing
Job Family Nursing
Job Type Perm Salary
Location Metrowest Boston

Coordinate and manage all aspects of patient care for the high-risk and very high-risk population in an ambulatory setting.


  • Develop a plan of care, coordinate services and navigate the patient through the health care system with to enable the patient and family to effectively manage their condition(s) and optimize outcomes
  • Performs a comprehensive care management assessment of patient needs to ensure safety at home
  • Coordinate effective transitions of care and effective hand-offs to the next level of care across the entire continuum, as needed
  • Utilizes available reports to proactively prioritize the needs of the patients and coordinates interventions
  • Conducts outreach to keep targeted patients aligned by PCP based on risk stratification
  • Designs transition of care plans with the patient and care team
  • Actively participates in roster review and other collaborative care initiatives with the practice staff for data collection, health reporting outcomes, clinical audits and programmatic evaluations
  • Document and report all quality and patient safety events by recording and adhering to all safety reporting guidelines


  • Graduate of a state-approved school of nursing, BSN preferred
  • Certified Case Management (CCM) or CCM eligible strongly preferred
  • Possess a current unrestricted RN licensure in the Commonwealth of Massachusetts
  • Possess an active Basic Cardiac Life Support (BCLS) certification
  • Minimum of 3-5 years' care management experience required
  • Ability to travel to select practice sites for meetings with patients, PCP and other members of the care team

Position ID: 38922