Ambulatory RN

The Job

Martin Luther King, Jr. Community Hospital is looking for an Ambulatory RN Care Manager to work in Los Angeles, CA. This isn't a floor nursing role; it's about managing the whole picture for patients ; helping them transition out of the hospital, stay on track with their health, and avoid coming back. You'll work closely with their doctors and care team to build a plan that actually fits their life.

What You'll Actually Do

• Partner with Primary Care Providers and the full healthcare team to create a smooth transition from hospital to home for each patient.
• Monitor each patient's progress, spot roadblocks, and adjust the care plan when things go off course.
• Meet with patients and their families to build a personalized healthcare pathway that works for both the short term and long term.
• Explain the RN Care Manager role, help initiate the health plan, and provide education on treatments, procedures, medications, and continuing care needs.
• Identify high risk patients who need extra coordination to prevent readmissions or emergency department visits.
• Manage patients with chronic diseases by following established protocols and working closely with providers.
• Develop and implement individualized education or care plans based on each patient's learning needs.
• Review, evaluate, and update the plan of care on an ongoing basis.
• Communicate with a multidisciplinary team ; physicians, nurses, therapists, social workers ; to support disease management.
• Help patients set self management goals and track their progress.
• Oversee and assist patients with referral navigation.
• Initiate disease specific care conferences when needed.
• Use motivational interviewing and other communication strategies to involve patients in their own care plans and goals.
• Assess a patient's readiness for change and use that to build self management goals.
• Participate in confidence level assessments and patient surveys to improve disease management care delivery.
• Document all disease management encounters using standardized processes.

What You Need

• A Bachelor of Science in Nursing is preferred.
• At least one to three years of hospital inpatient or related experience is required.
• You can navigate and connect successfully with outside provider networks including Health Plans, IPAs, and FQHCs.
• A current California nursing license.
• Certification in Case Management is preferred.
• Bilingual language skills (Spanish) are preferred.
• Basic computer skills.
• A current Basic Life Support (BLS) certification.