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Erie County Medical Center NURSE CASE MANAGER (AMBULATORY SERVICES) in Buffalo, New York

DISTINGUISHING FEATURES OF THE CLASS: The work involves developing and coordinating individualized patient care services utilizing the case management model for patients of the Ambulatory Services Department (outpatient care) at the Erie County Medical Center Corporation. The incumbent develops, coordinates and manages care plans for high-risk patients including, but not limited to, patients with multiple chronic conditions, HIV/AIDS, and/or significant behavioral health conditions. The incumbent will work directly with the patient/caregiver to explain the care plan in detail and communicate expectations of the patient for improving his/her health status. The incumbent serves as a liaison for the Ambulatory Department and collaborates with allied functions to provide an interdisciplinary team approach to achieve quality patient care, desired patient outcomes in a time-efficient, and cost efficient manner. Work is performed under the general supervision of higher-level professional nursing staff for clinical matters and an Ambulatory Services Department administrator for non-clinical matters. Supervision is exercised over lower-level nursing, paraprofessional, clerical and support staff. Does related work as required.


Identifies the targeted high-risk population for receipt of care management services by utilizing primary care practitioner referrals, risk stratification and patient lists;

Conducts comprehensive health assessments to identify medical, behavioral health and social service needs of patient;

Develops comprehensive, measurable and goal-oriented patient care plans in collaboration with patient, caregiver and interdisciplinary care team of internal and external care providers;

Provides information to patient/caregiver about disease management, medication treatment adherence, psychosocial health issues and health maintenance strategies;

Assesses health care, educational, and psychosocial needs of the patient/family throughout duration of care by utilizing standardized assessment tools such as depression screening, functionality and health risk assessment;

Revises the care plan as necessary; communicates with patient/caregiver and interdisciplinary team; makes required changes in patient electronic medical record;

Provides patient self-management support with a focus on empowering the patient/caregiver to build capacity for self-care;

Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations;

Coordinates completion of pre-visit planning work prior to patient visit as possible; provides follow-up contact with patient/caregiver for compliance with care plan on matters such as taking medications as prescribed, attending medical appointments and maintaining proper diet;

Acts as an advocate for patient and his/her care needs and conduct patient case conferences; communicates with health insurance provider as needed as it relates to patient care plan;

Collaborates with practice and clinical leadership to continuously evaluate processes, identify issues, and develop recommendations to improve care management model; assists in the implementation of making changes to the care management model;

Completes appropriate clinical records and tracking on a timely manner in compliance with applicable regulatory requirements and, as needed, health insurance provider guidelines;

Participates in and may organize meetings, conferences, trainings, in-services, professional events, community events, etc.


Thorough knowledge of the principles, practices, terminology and equipment associated with professional nursing in general and in an ambulatory services/outpatient care setting; thorough knowledge of the principles and practices of nursing case management; thorough knowledge of applicable laws, rules, regulations, accreditation standards, and ECMCC policies and procedures; thorough knowledge of available community resources for patients undergoing medical care associated with an ambulatory services setting; good knowledge of health insurance provider payer guidelines; ability to screen patients, assess health status and determine patient care needs; ability to develop and communicate comprehensive patient care plans; ability to link patients with available community resources; ability to supervise lower-level staff; ability to communicate effectively, both orally and in writing; ability to establish and maintain effective working relationships with a diverse constituency; ability to utilize a variety of electronic software applications; sound professional judgment; capable of performing the essential functions of the position with or without reasonable accommodation.


  • Graduation from a regionally accredited or New York State registered college or university with a Master's Degree in Nursing and two (2) years of professional nursing experience in an ambulatory services setting*; or:

  • Graduation from a regionally accredited or New York State registered college or university with a Bachelor's Degree in Nursing and four (4) years of professional nursing experience, of which two (2) years were in an ambulatory services setting*; or:

  • An equivalent combination of training and experience as defined by the limits of (A) and (B).


    Possession of a license and current registration to practice as a Registered Professional Nurse in New York State at time of appointment and maintenance throughout duration of employment;

    Possession of Basic Life Support (BLS) Certification at time of appointment and maintenance throughout duration of employment.

    *NOTE 1: Ambulatory Services is defined, for qualifying purposes, as medical care in which patients are admitted, treated and discharged all on an outpatient basis. Examples include outpatient community-based practices, hospital clinics, outpatient dialysis, emergency room, outpatient rehabilitation services, infusion, dentistry, and ambulatory surgery centers.

    NOTE 2: Verifiable part-time and/or volunteer experience will be pro-rated toward meeting full-time experience requirements.