Description

Location: Bronson Healthcare Group
Schedule: Part-Time (32 hours/week)

Love Where You Work
Team Bronson is compassionate, resilient, and strong. We are driven by positivity which inspires us to be our best and go above and beyond for our patients, for one another, and for our community.

If you're ready for a rewarding new career, join Team Bronson and be part of the experience.

 
Position Overview
The Ambulatory Care Manager provides care management and coordination for adult and pediatric patients with complex health conditions within the primary care setting. Working under minimal supervision, this role partners closely with physicians, specialists, care teams, and community resources to ensure patients receive high-quality, efficient, and cost-effective care.

The Ambulatory Care Manager assesses patient needs, develops individualized care plans, coordinates services across healthcare settings, and supports patients and families in managing chronic conditions. This role focuses on improving patient outcomes while helping prevent unnecessary hospitalizations, emergency department visits, and readmissions.

This position manages a caseload of approximately 150 complex patients (may vary depending on practice needs and patient complexity).

Key Responsibilities
Care Management & Coordination

•       Identify high-risk patients through provider referral, risk stratification, and patient lists
•       Conduct ongoing assessments of patients’ clinical, educational, and psychosocial needs
•       Develop and implement individualized care plans in collaboration with physicians and interdisciplinary teams
•       Coordinate care across multiple healthcare settings including hospitals, specialists, and post-acute services
•       Monitor patient progress and adjust care plans as needed to improve outcomes

Patient Support & Education

•       Provide self-management support to help patients better manage chronic conditions
•       Educate patients and families on care plans, medications, warning signs, and follow-up care
•       Help patients understand healthcare options and navigate available services

Transitions of Care

•       Provide follow-up after hospital discharge including:
•       Medication reconciliation
•       Scheduling primary care or specialist follow-ups
•       Reviewing discharge instructions
•       Addressing barriers to care
•       Ensure continuity of care during transitions between healthcare settings

Clinical Interventions

•       Implement evidence-based clinical guidelines and protocols
•       Monitor high-risk patients to prevent acute exacerbations
•       Utilize standardized screening tools such as depression screenings and health risk assessments

Collaboration & Program Improvement

•       Collaborate with physicians, care teams, community agencies, and payors
•       Participate in care management program development and process improvement initiatives
•       Analyze data and outcomes to improve care delivery and program performance

Documentation & Communication

•       Maintain accurate documentation of care management activities
•       Communicate regularly with patients, providers, and interdisciplinary teams
•       Provide updates and information necessary for coordinated patient care

Requirements

Education

• Bachelor’s degree (BSN or BS) required, or enrollment in a BSN program with completion within 6 months of hire

Experience

• 2–5 years of nursing experience required in one of the following areas: 
• Primary care or ambulatory care
• Home health
• Skilled nursing facility
• Hospital medical-surgical setting
• Experience with chronic care management or primary care preferred
• Discharge planning experience in acute or post-acute care settings preferred

Licensure

• Current Registered Nurse (RN) license in the State of Michigan
• Current CPR certification
• Must maintain BLS certification through RQI simulation
   

Skills & Competencies

• Strong patient assessment and triage skills
• Knowledge of chronic disease management and evidence-based clinical guidelines
• Ability to analyze complex clinical information and make informed decisions
• Excellent communication and relationship-building skills
• Ability to work independently while collaborating across multidisciplinary teams
• Strong problem-solving, organization, and time management abilities
• Experience with documentation systems and standard office software