Ambulatory Care Manager; Registered Nurse Bronson Primary Car

Ambulatory Care Manager (Registered Nurse)

Location:

Bronson Methodist Hospital, Richland, MI. Full time, 40 hours per week.

The Ambulatory Care Manager provides care management and care coordination for adult and pediatric patients with complex illness in the primary care setting. The role collaborates with the ambulatory care management team, practice leadership, specialists, managed care, and patients/families to ensure delivery of quality, efficient, and cost‑effective health care services.

• Perform patient assessments, develop patient‑centered care plans, and implement interventions.
• Coordinate care across settings and help patients/families understand health care options.
• Manage a caseload of approximately 150 complex patients, providing targeted interventions to reduce hospitalization, emergency room visits, and readmissions.
• Integrate evidence‑based clinical guidelines and preventive protocols in individualized care plans.
• Monitor and evaluate patient responses, revising care plans as indicated.
• Provide patient self‑management support focused on empowerment and capacity building.
• Implement systems of care that facilitate close monitoring of high‑risk patients to prevent acute exacerbations.
• Coordinate follow‑up after hospital discharge, including medication reconciliation, PCP or specialist appointments, and barrier resolution.
• Maintain required documentation for all care management activities.
• Work with ambulatory care management, managed care, and practice leadership to evaluate processes, identify problems, and propose process improvement strategies.

• Bachelor's degree (BSN or BS) or enrollment in a BSN program with completion within 6 months of hire.
• Two to five years of nursing experience with adult and pediatric patients in primary care/ambulatory care, home health, skilled nursing facility, or hospital medical–surgical setting.
• Experience in chronic care management and primary care desirable; discharge planning experience for acute or post‑acute care also desirable.
• Licensed RN in good standing with the State of Michigan.
• Current CPR certification and adherence to department standards for maintaining BLS certification through RQI simulation.
• Proficiency with word processing, spreadsheets, presentations, databases, and other relevant software.
• Excellent customer‑focused interpersonal skills and ability to interact effectively with practitioners, interdisciplinary team members, community agencies, patients, and families.
• Ability to work autonomously, be directly accountable for practice, and demonstrate leadership qualities including time management, communication, critical thinking, and decision‑making.
• Strong written, verbal, and listening communication skills, with a positive customer relations orientation.