Job Description

Job Title:                             Ambulatory RN Care Manager


The Care Manager (CM) serves in an expanded nursing role, collaborates with patients with complex comorbid conditions, support systems, primary care providers, as well as all providers of care and services involved in delivering a patient’s care. The CM performs duties to support the goals and objectives of Montage Medical Group’s model of care management to ensure delivery of quality healthcare that focuses on providing excellent patient care and achieving a high level of patient satisfaction.


The CM oversees care management and care coordination of health care services within the Montage Medical Group physician offices. The CM may be deployed to multiple care settings based on organizational needs at the discretion of the employer. CMs use standardized tools and assessments to track, monitor and coordinate care plans for assigned patients, and ultimately work to discharge patients from care management once patients meet their care plan goals. 


Many patients will have multiple conditions and co-morbidities and/or psychosocial needs. The CM will develop an effective, supportive relationship with the patient/family to facilitate achievement of the health goals. They will interact and collaborate with interdisciplinary care teams, which include physicians, discharge planners, inpatient care managers, referral coordinators, pharmacists, laboratory technologists, social workers, dietitians, educators, nurses, health plan, and other healthcare team members. The CM serves as an advocate for patients and their families, providing links to relevant community resources and services for continued growth toward their maximum level of independence. The CM helps patients gain insights and knowledge of their chronic condition(s) to maximize self-management of their condition in the least restrictive level of care.


Montage Medical Group (MMG), part of the Montage Health system, is operated as a licensed community clinic following California Department of Public Health title 22 statutes. MMG employs approximately 180 staff members with roughly 85 physicians and advance practice providers, seeing approximately 135,000 patient visits annually. The person in the position of the RN, Population Health Services Director must be able to perform the duties described within as well as to meet the company’s qualifications regarding education, experience, patient service, attitude, language skills, meet physical requirements, possess strong clinical and analytical skills. 


ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. 

  • Assesses the healthcare, educational, and psychosocial needs of patients and their families.
  • Collaborates effectively and fosters team approach with patient/family, the Primary Care Physician (PCP) and care team to develop short- and long-term health goals, along with a detailed Care Plan to achieve those goals.
  • Partners with PCPs to ensure care adherence and integration of evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics to develop patient-centered treatment plans; also initiates or adjusts therapies and promotes proven practice as directed by the practitioner and provides appropriate follow up and monitoring as needed.
  • Triages patients to appropriate care service using risk and screening criteria and clinical aptitude.
  • Develops and implements self-management plan with patient which prevents exacerbation or intervenes early during acute increased severity of disease or its signs and symptoms.
  • Educates and documents patient care plan goals and measures which results in greater control of their health status, mutually agreed upon interventions and progress or barriers.
  • Makes referrals to community agencies and resources as appropriate.
  • Coordinates with family to facilitate communication.
  • Coordinates care efforts for a safe, effective, efficient and patient centered transition along the health continuum.
  • During times of patient hospitalization or ER visits, works collaboratively with hospital staff and Transitional Care Managers to assess the need for appropriate level of care and develops appropriate action plan with the PCP, patient and family.
  • Coordinates consults/referrals, hospital/ER, community resource follow-up and tracking processes for the PCP practice to improve patient transitions and the flow of information.
  • Participates in and presents case studies to the interdisciplinary team meetings including clinical assessments, updating of care plans and determination of follow-up frequency.
  • Intervenes on behalf of the patient and organization to reduce avoidable emergency room visits or unnecessary hospital admissions and readmissions.
  • Monitors patient status against appropriate outcomes and addresses clinical issues with the attending physician and care team to optimize outcomes.
  • Creatively explores alternatives or work around options with patient and family, to resolve barriers and meet health care goals.
  • On a daily basis: triages incoming referrals; assists with scheduling PCP or specialist appointments; checks upcoming appointments for existing patients to meet them face-to-face; conducts intake visits; places recruitment calls; places outreach calls; coordinates care and conducts pre-visit planning; works with insurance partners; and works with community resources and vendors to ensure coordinated care.
  • Maintains collegial relationships with medical neighborhoods, medical suppliers and community agencies/resources available to patients within Monterey County and beyond.
  • Ensure patients receive quality services and products in the most cost-effective manner.
  • Manages practice metrics to further refine delivery of care model and enhance clinical, quality, and fiscal outcomes.
  • Works with population health management division leadership to continuously evaluate processes, identify problems, and propose process-improvement strategies that enhance the Advanced Medical Home delivery of care model
  • Uses appropriate conflict resolution, assertiveness, negotiation, and collaboration skills to engage patient and family throughout the healthcare process.
  • Works with physicians and Director to develop protocols and point of care reminders using nationally recognized evidence-based care measures and outcomes, such as: Diabetes, HF, COPD and CAD.
  • Works with physicians and Director to define quality measures/ outcomes reporting process.
  • Other duties as assigned.

EDUCATION:  Current RN licensed in the state of California. American Heart Association BLS. Minimum one year recent (in past three years) clinical nursing experience.

EXPERIENCE:  Experience as an RN Care Management or in a Medicare and Medi-Cal environment (Home health, Skilled Nursing, Physician Office, Clinic, Hospital).  Experience with electronic medical record documentation.

REQUIREMENTS:   California licensed registered nurse.

PREFERRED: Bilingual English/Spanish. Bachelors of Science in Nursing (BSN). Knowledge of Monterey County community resources. Experience as a care manager in an Advanced Medical Home.


KNOWLEDGE:  The jobholder must demonstrate current competencies applicable to the job position.

  • Problem resolution skills
  • Excellent customer service
  • Critical thinking skills and ability to analyze datasets
  • Effective verbal and writing skills
  • Microsoft Office knowledge (Word, Excel, and Outlook)
  • Demonstrates customer-focused interpersonal skills and interacts effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families who may have diverse opinions, values, and religious and cultural ideals.
  • Demonstrates ability to work autonomously and be directly accountable for results
  • Demonstrates flexibility
  • Exhibits capability to influence and negotiate individual and group decision making
  • Possesses skills to function effectively in a fluid, dynamic, and rapidly changing environment
  • Displays proven ability to positively influence behavior and outcomes


  • Skill in appropriate assessment and assistance techniques.
  • Skill in appropriate use of universal precautions, safe workplace and confidentiality methods.
  • Skill in health information management by appropriately charting patient data.


  • Ability to work effectively as a team member with physicians and other staff.
  • Ability to react calmly and effectively in emergency situations.
  • Ability to appropriately interact with patients, families, staff and others.
  • Ability to flexibly respond to changing demands.
  • Ability to plan, organize, prioritize and direct the work of others.
  • Ability to communicate clearly.