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

Bronson Healthcare•Kalamazoo, MI

26d

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 healthcare team members, and patients and families to support quality, efficient, and cost-effective care. The manager assesses patients, develops and implements individualized, patient-centered care plans, coordinates services, and monitors outcomes to optimize health. The role uses evidence-based clinical and preventive guidelines and protocols. It manages a caseload of approximately 150 complex patients, which may vary by practice needs and patient complexity, and provides targeted interventions to support self-management and help prevent hospitalization, emergency visits, and readmissions. The manager also coordinates care across settings and helps patients and families understand their healthcare options.

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 RN license in good standing with the State of Michigan.
Maintain current CPR certification and meet department and Bronson requirements for staying current with BLS through RQI simulation.
Ability to use word processing, spreadsheet, presentation, database, and other job-related software.
Customer-focused interpersonal skills for working effectively with practitioners, interdisciplinary 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 abilities, including time management, oral 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 maintain appropriate boundaries.
Excellent written, verbal, and listening communication skills, relationship-building skills, and critical-analysis skills.
Ability to effect change, work productively and 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.
Critical-thinking skills and ability to analyze complex data sets and manage complex clinical issues using assessment skills and protocols.
Excellent assessment and triage skills, with the ability to implement evidence-based interventions and protocols for chronic conditions.

Nice To Haves

Experience in chronic care management and primary care.
Discharge-planning experience in an acute-care or post-acute-care setting.

Responsibilities

Identify targeted high-risk patients using PCP referrals, risk stratification, and patient lists, including patients experiencing repeated social or health crises.
Assess patients’ and families’ healthcare, educational, and psychosocial needs over time using standardized tools, including depression, functionality, and health-risk assessments.
Collaborate with PCPs, patients, families, healthcare teams, community partners, and care-setting providers to develop comprehensive, individualized care plans and targeted interventions.
Monitor patients’ and families’ responses to care plans and revise plans as needed.
Provide self-management support that empowers patients and families to build capacity for self-care.
Implement systems for monitoring high-risk patients and intervening early during acute exacerbations.
Apply clinical interventions and protocols based on risk stratification and evidence-based guidelines.
Coordinate care through ongoing collaboration and promote continuity beyond practice boundaries; serve as a liaison to acute care hospitals, specialists, and post-acute care services.
Follow up with patients and families after transitions between care settings, including timely post-hospital follow-up, medication reconciliation, follow-up appointments, symptom assessment, warning-sign education, discharge-instruction review, care coordination, and resolution of barriers.
Maintain required documentation for care management activities.
Use problem-solving and critical-thinking skills in longitudinal care management and transitions of care; use negotiation and conflict-resolution skills when needed.
Work with ambulatory care management, managed care, and practice leadership to evaluate processes, identify problems, and develop improvement strategies to enhance care management and meet program and payor metrics.
Communicate with patients, physicians, interdisciplinary team members, third-party payors, community agencies, and other healthcare professionals to exchange information and discuss findings.