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Mobile Ambulatory Case Manager

Cape Cod Healthcare

Hyannis, MA
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Cape Cod Healthcare
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Job Details

Cape Cod Healthcare

Department: HCI Phys Health Org - PHO
Schedule: Full-time 40 Hours per week
Shift: Day Shift
Hours: 8a-5p Monday-Friday
Job Details: Cape Cod Healthcare is the leading provider of healthcare services for residents and visitors of Cape Cod.  With more than 450 physicians, 4,700 employees, and 1,100 volunteers, Cape Cod Healthcare operates two-acute care hospitals, the Cape's leading provider of homecare and hospice services (VNA), a skilled nursing and rehabilitation facility (JML Care Center), an assisted living facility (Heritage at Falmouth), the Cape's only local laboratory service (CCHC Laboratory Services) and numerous health programs.  We are currently seeking a dedicated Mobile Ambulatory Case Manager to join our team at Cape Cod Healthcare.   


Cape Cod Healthcare offers competitive salaries, excellent benefits packages, tuition reimbursement, and generous paid time off.



Perform a comprehensive care management home visit, including assessing physiological, psychological and environmental factors, and a health history. Integrates all pertinent data gathered on assessment and identifies problems that form the basis of a plan of care. Interacts with the physician and develops a plan of care based on the defined standards of care.  Utilizes the team-leader approach when optimizing patient clinical care.



1.     Exhibits a commitment to the mission, vision and goals of the organization and demonstrates a respect for working in a collaborative decision-making process by incorporating continuous quality improvement.

2.     Communicates in a clear and effective manner with patients, patient families, caregivers, physicians  and other health care personnel.

3.     Shows empathy and compassion in his/her care delivery; makes an effort to understand the circumstances affecting the patient and their health care.

4.     Ability to communicate with patients of varying educational levels, backgrounds and cognitive levels.

5.     Demonstrates excellent care to his/her patients, their families and caregivers and shows a vested interest in the wellness of the patient.

6.     Travels to, and works in, patient's place of residence.

7.     Patient visits are scheduled in a timely manner, or as prescribed per policy.

8.     Assess the patient's home environment to identify potential risks and barriers to health and wellness and makes appropriate referrals as needed.

9.     Complete an at-home visit that includes a comprehensive case management assessment, taking into considerations physiological, psychological and environmental factors as well as health history.

10.  Perform a home visit with the patient at least 2 times per month with more home visits based on patient needs.

11.  Communicates with physicians, family, caregivers and other involved care providers to develop, implement and complete the care plan.

12.  Integrates all pertinent data gathered on assessment and identifies problems that form the basis of a plan of care.

13.  Set goals in concert with the patient and his/her PCP that are realistic, quantifiable and based on desired outcomes that are supported by our standards of care.

14.  Adheres to defined plan of care and adjusts the plan of care as appropriate based on patient's status and data collected upon reassessment.

15.  Regularly meets with PHO clinical team and Medical Director for patient case management review as scheduled or more frequently if necessary.

16.  Collaborates with and is responsible for coordination with other disciplines participating in the Plan of Care (i.e., Dietician, physician, SNF/rehab., community resources, VNA).Participates in multi-disciplinary patient case conferences; evaluates effectiveness of patient care.

17.  Notifies PCP and other care providers of significant changes in the patient's condition or care plan as it deems appropriate.

18.  Reassesses the plan of care at regular intervals.

19.  Discharges patient when goals are met.

20.  Demonstrates follow through of the care plan with the patient.

21.  Documents the patient's care in the case management systems. Documentation is timely, clear, concise, and addresses specifics of teaching and care management.

22.  Keeps manager and other appropriate personnel informed as to the status of our patient caseload.

23.  Maintain an accurate and appropriate case census and report data to manager or others as requested.

24.  Focuses on the customer as a patient and prioritizes workload.  Anticipates and responds to patient needs and ensures patient understanding and compliance through proactive counseling.  Addresses customer concerns and complaints related to service delivery, promptly and courteously both in person and on the telephone.

25.  Refers unresolved issues or issues outside scope of responsibility to the Director of Clinical Operations, as appropriate.

26.  Maintains a thorough understanding and ensures compliance of all regulatory and PHO Clinical Operations policy and procedures. 

27.  Maintains confidentiality of all work assigned and of all patient and/or employee information.

28.  Develops ongoing relationship with referral sources, including physicians, to keep them informed of the Helping Hands programs and to solicit feedback regarding the services provided.

29.  Performs other work related duties as assigned or requested.


Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare's commitment to CARES: compassion, accountability, respect, excellence and service.



  • Current RN license, in good standing, in Massachusetts.  BSN preferred.
  • Minimum of five (5) years of clinical nursing experience required.
  • Minimum of three (3) years of clinical nursing experience plus two (2) years of case management experience can be in lieu of the required five (5) years of clinical experience.
  • Driver's license in Massachusetts required.
  • CPR certification required.
  • Computer skills required.
  • Understanding of transition of care and ambulatory case management preferred.
  • Home Care experience preferred.

HR Use Only:

Zip Code: 02601
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