Ambulatory Care Management Associate
Company: Beaumont Services Center
Location: Southfield
Posted on: January 20, 2023
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Job Description:
Remote work opportunitiesAs the largest not-for-profit health
care system serving Michigan, we offer a world of opportunity
within our expansive system. We have more nationally ranked
hospitals than any other health system in the state, including six
that are Magnet -recognized. In total, Beaumont has eight hospitals
and 155 outpatient sites that provide diverse practice settings
located in communities throughout southeastern Michigan and the
greater Detroit metropolitan area.GENERAL SUMMARY:Supports care
management and care coordination for patients with complex
conditions and those with mild to moderate chronic illness. With
direction and input from the Ambulatory RN Care Coordinator (CC),
supports care management and population management initiatives with
the team through process improvement and patient care coordination.
Responsibilities include collaboration with patients and the care
team to ensure coordination of patients clinical and social care
needs.ESSENTIAL DUTIES:1. Coordinates care with a targeted
high-risk population and chronically ill population within practice
sites through patient interaction both telephonically and via face
to face encounters. Implements and supports the healthcare,
educational, and psychosocial plan of the patient/family created by
the care team.2. Collaborates with Primary Care Physician,
Ambulatory RN CC, patient, and members of the health care team, to
assess, develop and implement an agreed upon plan of care.
Participates in continuous quality improvement to enhance care
management in the office setting. Monitors patient/family response
to plan of care and revises the care plan as indicated under the
direction of the care team. Provides self-management support with a
focus on empowering the patient/family to build capacity for self-
care. Ensure support for advanced directives and advanced care
planning.3. Collects patient reported information and reports to
the RN CC in order complete a comprehensive assessment to identify
the member's needs, self-management goals, functional and/or
cognitive impairment, psychosocial issues, environment, and areas
of risk or barriers that may impact the patient's adherence to the
care management plan.4. Implements systems to ensure necessary care
is completed and monitors individual patient progress and
population health. Coordinates patient care by linking patients to
resources. Provides follow up with patient/family when patient
transitions from one setting to another. Completes post hospital
discharge calls appropriate to skill set, including medication
reconciliation, coordinates physician follow-up appointments,
symptoms assessment and patient education/ discharge instructions,
and problem-solves barriers to compliance.5. Maintains required
documentation for all care management activities. Works with
practice and care team to continuously evaluate processes, identify
problems, and propose/develop process improvement strategies to
enhance the Patient Centered Medical Home delivery model and
value-based payer program requirements.6. Reviews the current
literature regarding effective engagement and communication
strategies, care management strategies, and behavior change
strategies and incorporates into clinical practice.7. Provides
education allowed under their defined scope of practice on
management of chronic conditions and enhances the member's
self-efficacy to prevent progression or exacerbation of chronic
illness and promote healthy behavior change. Coordinate care
transitions and monitoring of high-risk members following hospital
and sub-acute discharges to ensure timely follow-up with primary
care and prevent readmissions.This document represents the major
duties, responsibilities, and authorities of this job, and is not
intended to be a complete list of all tasks and functions. It
should be understood, therefore, that incumbents may be asked to
perform job-related duties beyond those explicitly
described.STANDARD REQUIREMENTS:1. Supports the Mission, Value and
Vision of Beaumont Health (BH). Demonstrates personal commitment
through active involvement in the performance improvement
process.2. Exhibits excellent customer service skills and behaviors
toward internal and external customers and co-workers. Promotes
positive public relations with patients/residents, family members,
guests, and others.3. Supports and adheres to all Beaumont Health's
customer service, service excellence, and performance standards.
Supports and participates with all required compliance standards
that may be department specific and/or identified by the
organizations including in-service training, acceptable attendance,
uniform and dress code.4. Adheres to HIPAA requirements and
maintains confidentiality of all data, including patient/resident,
employee and operations information.5. Supports and participates in
a collaborative team-oriented environment - cooperates and works
together with all co-workers, plans and completes job duties, uses
appropriate communications in sensitive and emotional situations
and follows up as appropriate regarding reported complaints,
problems and concerns.6. Supports, cooperates with and demonstrates
safe work practices and attitudes, follows safety rules - including
universal precautions - reports and prevents/corrects unsafe
conditions and behaviors, and participates in organizational and
departmental safety programs.7. Completes all required compliance
standards that may be department specific and/or identified by the
organization.8. Maintains current licensure, registration and/or
certification, as applicable, at all times.STANDARD
QUALIFICATIONS:To perform this job successfully, an individual must
be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge,
skill and/or ability required. Reasonable accommodations may be
made to enable individuals with disabilities to perform the
essential duties.A. Education / Training: Graduate of an accredited
school or program for Licensed Practical Nursing or other
clinically related area with a technical or college-level degree.B.
Work Experience: Minimum two years' experience in the clinical care
setting. One to two years' experience in physician practice setting
preferred. Care management, home care and/or discharge planning
experience preferred.C. Certification, Licensure, Registration: If
licensed, requires a current, unrestricted license to practice as
required in the State of Michigan. If certified, requires a
current, valid certification in related specialty.D. Other
Qualifications: Excellent interpersonal and communication skills.
Ability to act in an autonomous, self-directed manner in a
fast-paced, ever-changing environment. Knowledge of chronic disease
implications, evidence-based guidelines, prevention, wellness,
health risk assessment, and patient education. Excellent judgement,
data collection, problem solving, and triage skills Proficient in
computer skills and applications including Excel workbooks Ability
to affect change, work as a productive and effective team member,
to be flexible, and adapt to needs/priorities 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.Beaumont offers a
comprehensive benefits package to meet your financial, health and
life-work balance goals.NEW On-demand pay program - powered by
PayactivGenerous paid time off, holidays and flexible schedulingOur
employees receive special discounts on a wide range of products and
servicesExceptional health, dental, vision and prescription drug
insurance plansRelocation assistanceGenerous retirement savings,
disability insurance, identify theft protection and even home and
auto insuranceWORKING CONDITIONS:A. Physical Effort: Position
requires incumbent to occasionally perform physical activities
necessitating ability to push/pull objects up to 20 pounds.
Mobility skills such as walking and standing along with performing
manual dexterity and coordination functions required.B. Work
Environment: Incumbent may be occasionally exposed to blood, body
fluids, and hazardous substances.Our diverse and talented teams of
professionals and clinicians don't just share in the success of our
system; they make it possible. Driven by our shared commitment to
making our communities healthier and stronger, we are leading the
way in health care innovation with relentless ambition and a belief
that anything is possible when we work together.This is where
extraordinary begins. Find out where it can take you and your
career. Apply Now!Beaumont Health grants equal employment
opportunity to all qualified persons without regard to race, color,
national origin, sex, disability, age, religion, genetic
information, marital status, height, weight, gender, pregnancy,
sexual orientation, gender identity or expression, veteran status,
or any other legally protected category.
Keywords: Beaumont Services Center, Southfield , Ambulatory Care Management Associate, Executive , Southfield, Michigan
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