Ambulatory Care Manager

Bronson Healthcare

About The Position

The Ambulatory Care Manager provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. The Ambulatory Care Manager serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practice leadership, consulted specialists, managed care, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. The Ambulatory Care Manager performs patient assessments, develops patient centered care plans, implements interventions, coordinates care, and monitors and evaluates all options and services with the goal of optimizing the patient’s health status. The Care Manager integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. The Ambulatory Care Manager manages a caseload of approximately 150 complex patients (caseload may vary based on practice needs & complexity). The Care Manager provides targeted interventions to these high risk patients to increase self-management and prevent hospitalization, emergency room visits, and/or readmissions. The Ambulatory Care Manager coordinates care across settings and helps patient/families understand health care options.

Requirements

Bachelor's degree (BSN or BS) or enrolled in a BSN program with completion within 6 months of hire required.
Two to five years of experience in nursing with adult and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting required.
Licensed RN in good standing with the State of Michigan required.
Must maintain current CPR certification and follow department standards and Bronson policy for maintaining and staying current with BLS through RQI simulation.
Ability to utilize word processing, spreadsheet, presentation programs, databases, and other software relevant to the job.
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Demonstrates ability to work autonomously and be directly accountable for practice.
Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
Requires excellent communication skills and a positive customer relations orientation.
Regularly communicates both orally, face to face and/or by telephone, and in writing with patients.
Communicates with physicians, members of the interdisciplinary team, third party payors, community agencies, and other healthcare professionals to discuss findings, answer questions, and obtain or exchange information pertinent to their information requirements.
Work which is constantly and exceptionally tiring mentally and/or visually. Conditions exist more than 90% of the work time.
Involves regularly lifting of bulky or moderately heavy weights (i.e., up to 50 pounds), and occasionally assisting with heavier tasks or expending the equivalent effort in pushing, pulling, or otherwise handling material, equipment, and other objects.
Demonstrates effective problem-solving and critical thinking in care for patients in longitudinal care management and during transitions of care.
Regularly utilizes effective negotiation and conflict resolution skills as needed.
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.
Ability to manage complex clinical issues utilizing assessment skills and protocols
Excellent assessment and triage skills.
Ability to implement evidence base interventions and protocols for chronic conditions

Nice To Haves

Experience in chronic care management and primary care is desirable as is discharge planning experience for the acute care or post- acute care setting.

Responsibilities

Identifies the targeted high risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community.
Responsible for developing a comprehensive individualized plan of care and targeted interventions.
Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
Provides patient self-management support with a focus on empowering the patient/family 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.
Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.
Fosters a team approach and includes patient/family as active members of the team.
Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
Provides follow-up with patient/family when patient transitions from one setting to another.
Completes timely post-hospital follow-up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
Maintains required documentation for all care management activities.
Works with ambulatory care management, managed care, and practice leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and ensure care management program & payor metrics are met.