Job description
CURRENT BRONSON EMPLOYEES - Please apply using the career worklet in Workday. This career site is for external applicants only.
Love Where You Work!
Team Bronson is compassionate, resilient and strong. We are driven by Positivity which inspires us to be our best and to 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.
Location
BHG Bronson Healthcare Group
Title
Ambulatory Care Navigator, MA
Supports ambulatory care management team and primary care practices through hospital and emergency department follow-up calls and coordinates care as needed. Supports patients across the continuum through gaps in care, disease management, and resource (Social Determinants of Health (SDoH)) support. Serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practices, 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. Assists with and updates as needed: 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. Follows evidence-based clinical guidelines, preventive guidelines, and protocols in care delivery for the patient.
Supports low to rising risk patients (workload may vary based on needs & complexity). Provides support in targeted interventions to this patient population to increase self-management and prevent hospitalization, emergency room visits, and/or readmissions. Coordinates care across settings and helps patient/families understand health care options. Emphasis of duties may vary depending upon the area of assignment.
Current Certified or Registered Medical Assistant in the state of Michigan and two to five years of experience in a healthcare setting with adult and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting.
Experience in primary care is desirable experience as well as the acute care or post-acute care setting.
-
Ability to use word processing, spreadsheets, presentation programs, 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 leader 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, ongoing relationships and set appropriate boundaries with others.
-
Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
-
Critical thinking skills and ability to analyze data sets. Ability to manage issues/barriers utilizing assessment skills, resources, and standard work.
-
Ability to implement evidence-based interventions and protocols to support patient health.
-
Flexibility to adapt to the needs of the department.
-
Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.
-
Identifies patients for hospital/ED outreach follow-up through reports and prioritizes using risk stratification tools.
-
Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: schedule PCP or specialist follow-up appointments; assess for ongoing or new symptoms; review warning signs and discharge instructions, complete medication reconciliation, coordinate care, and problem solve barriers.
-
Identify high risk patient acuity and eligibility to initiate enrollment in Care Management.Connect patients with care manager and/or other resources as appropriate.Identify gaps in care for patients and provide appropriate outreach to the patient with the goal of closing the gap. Gaps in care and follow up may include (but not limited to): labs, immunizations or vaccinations, screenings, tests, annual wellness visit, advance care planning (ACP), and follow-up visits to support health maintenance across the continuum.
-
Identify patient needs from SDoH screening and coordinate resources or referrals as appropriate to support the physical and/or psychosocial need of the patient.Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
-
Coordinate patient care through ongoing collaboration with care team, PCP, patient/family, community, and other members of the health care system. Fosters a team approach and includes patient/family as active members of the team.Facilitate referrals as directed and needed for the patient.
-
Outreach and engage assigned patient population and identify care needs.Conduct regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
-
Maintains documentation for all patient outreach, care management and disease management activities in the patients electronic medical record.
-
Knowledge of health conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
-
Works with various teams across the system as needed to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient management.
-
Bill appropriate codes based on payor guidelines and direction of leadership.
Shift
First Shift
Time Type
Full time
Sign-On Bonus
External Candidates Only: Up to $1,500.00
Retention Bonus
External Candidates Only, $1,500.00
Scheduled Weekly Hours
40
Cost Center
1287 Centralized Disease and Care Management (BHG)
colinoncars.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, colinoncars.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, colinoncars.com is the ideal place to find your next job.