Ambulatory Care Manager, BLFC Bangor, PT 32 hours per week, (M, T, W &F), 0800-1630

Bronson Healthcare Group•Kalamazoo, MI

24d

About The Position

The Ambulatory Care Manager provides care management and coordination for adult and pediatric patients with complex illnesses in a primary care setting, under minimal supervision. The role collaborates with the ambulatory care management team, primary care practice leadership, specialists, managed care, other health care team members, and patients and families to support quality, efficient, and cost-effective care. The manager assesses patients, develops and revises individualized, patient-centered care plans, implements evidence-based interventions, coordinates care, and monitors outcomes. The position manages a caseload of approximately 150 complex patients, which may vary with practice needs and patient complexity, and provides targeted support to high-risk patients to improve self-management and help prevent hospitalization, emergency visits, and readmissions. The manager coordinates care across settings, supports patients and families in understanding care options, and helps ensure continuity during transitions of care. This is a part-time position scheduled for 32 hours per week, Monday, Tuesday, Wednesday, and Friday, 0800–1630. The posting lists the location as Kalamazoo-601 John St.-Medical Office Pavilion (South Campus).

Requirements

Bachelor’s degree (BSN or BS), or enrollment in a BSN program with completion within six months of hire.
Two to five years of nursing experience with adult and pediatric patients in primary care or ambulatory care, a home health agency, a skilled nursing facility, or a hospital medical-surgical setting.
Current registered nurse license in good standing with the State of Michigan.
Maintain current CPR certification and meet department standards and Bronson policy for maintaining current BLS through RQI simulation.
Ability to use word processing, spreadsheet, presentation, database, and other job-relevant software.
Customer-focused interpersonal skills for effective interactions with practitioners, interdisciplinary health care teams, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Ability to work autonomously and be directly accountable for practice.
Leadership skills, including time management, verbal and written communication, listening, problem solving, critical thinking, analysis, decision-making, priority setting, delegation, and work organization.
Ability to develop positive longitudinal relationships with patients and families and set appropriate boundaries.
Excellent communication, relationship-building, listening, and critical-analysis skills.
Ability to affect change, contribute effectively as a team member, and adapt to changing needs and priorities.
Excellent communication skills and a positive customer-relations orientation.
Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
Ability to analyze complex data sets and manage complex clinical issues using assessment skills and protocols.
Excellent assessment and triage skills.
Ability to implement evidence-based interventions and protocols for chronic conditions.
Ability to regularly communicate orally, face-to-face and/or by telephone, and in writing with patients, as well as communicate with health care professionals and community agencies.

Nice To Haves

Experience in chronic care management and primary care is desirable.
Discharge-planning experience in acute care or post-acute care is desirable.

Responsibilities

Identify high-risk patients using PCP referrals, risk stratification, and patient lists, including patients with repeated social or health crises.
Assess patients’ and families’ health care, educational, and psychosocial needs over time, using standardized tools such as depression screening, functionality, and health risk assessments.
Collaborate with primary care providers, patients, families, community resources, and health care team members to develop comprehensive individualized care plans and targeted interventions.
Monitor patient and family response to care plans and revise plans as indicated.
Provide self-management support that empowers patients and families to build capacity for self-care.
Implement systems to closely monitor high-risk patients and prevent or respond early to acute exacerbations.
Apply clinical interventions and protocols based on risk stratification and evidence-based guidelines.
Coordinate care through ongoing collaboration with primary care providers, patients and families, community resources, and other health care team members.
Promote a team approach that includes patients and families as active team members, and lead efforts to maintain continuity of care beyond practice boundaries.
Serve as a liaison to acute care hospitals, specialists, and post-acute care services, and follow up with patients and families during transitions between care settings.
Complete timely post-hospital follow-up, including medication reconciliation, follow-up appointments, symptom assessment, warning-sign education, discharge-instruction review, care coordination, and problem-solving around barriers.
Maintain required documentation of care management activities.
Use problem-solving, critical thinking, negotiation, and conflict-resolution skills in longitudinal care management and transitions of care.
Work with ambulatory care management, managed care, and practice leadership to evaluate processes, identify problems, and propose or develop process improvements that enhance care management and meet program and payer metrics.
Communicate with patients, physicians, interdisciplinary team members, third-party payors, community agencies, and other health care professionals to exchange information relevant to care.