RN Care Manager - Case Management
Company: Legacy Community Health
Posted on: November 19, 2023
RN Care ManagerLegacy Community Health is a premium, Federally
Qualified Health Center (FQHC) that provides comprehensive care to
community members regardless of their ability to pay. Our goal is
to treat the entire patient while improving their overall wellness
and quality of life, in addition to providing free pregnancy tests,
HIV/AIDS screening. At Legacy, we empower patients to lead better
lives by promoting healthy behaviors and offering resources such as
literacy classes, family planning services, and nutrition and
weight management information.
Our roots began in 1981 as the Montrose Clinic, with specialization
in HIV education, testing, and treatment. Since then, the agency
has expanded to 10 clinics in Houston, one in Baytown, two in
Beaumont, and one in Deer Park with extensive services that
include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and
maternity, dental, vision and behavioral health. We also service
students within KIPP and YES Prep schools. Legacy is committed to
driving healthy change in our communities.
The RN Care Manager (CM) is an integral member of the Care Team. RN
Care Managers are responsible for coordinating and managing the
holistic care of the high-risk, emerging high-risk, high-utilizer,
and chronic illness patients. Using a collaborative approach, the
CM will assess, plan, implement, monitor and evaluate the services
required to meet an individuals health/social needs. The CM is also
responsible for providing effective education techniques,
self-management support and helping to facilitate timely healthcare
* Work in collaboration with multidisciplinary team members to
address the unmet needs of the assigned population.
* Complete telephonic outreach and home/virtual visits as
applicable, based on patient acuity.
* Performs comprehensive health risk assessment/disease management
assessment that is consistent with the patients complex
chronic/co-morbid condition (s). These assessments also include the
identification of psycho-social care needs.
* Provides outreach, education and interventions for patients who
have excessive utilization patterns, where usual care management
approaches have been ineffective in preventing avoidable admissions
to the Emergency Room and Inpatient settings.
* Collaborate with the patient and care team to develop a
patient-centered care plan.
* Coordinates services with the patients care team including,
primary care team, specialists, home care, hospital team, managed
care organization and any others involved with the patients care to
optimize clinical outcomes.
* Routinely assesses patients progression towards goals and adjusts
* Assesses barriers when patient has not met stated goals, is not
following treatment plan of care, or has not kept important
appointments; facilitate appropriate resources/ referrals as
* Create a collaborative relationship with the patient in the
management of their health care status through education plans
related to health preserving, disease prevention, and disease
* Participates in regularly scheduled caseload rounds/consultations
with the care team, focusing on patients who are newly assigned to
the caseload or who are not improving as anticipated
* Refer patients to other entities for education as needed.
* Assist patient with the procurement of medical supplies when
* Maintains required medical documentation for care management
activities in the designated care management module.
* Follows standards of work and consistently maintains department
established caseloads and timeframes for case completion.
* Documents and reports all quality and patient safety events by
recording and adhering to all of Legacy Community Healths safety
* Participates in the refinement and/or development of new
standards of work.
* Maintains awareness of key performance indicators/metrics and
manages caseloads through coordinating interventions to prevent
avoidable ER visits, hospital admissions and readmissions.
* Attend staff meetings and education offerings both in person and
via teleconference/online as required.
* All other duties as assigned.
Education & Training Requirements
* Registered Nurse with an active, unrestricted Texas licensure
* State Board recognized nursing education
* 3-5 years acute clinical experience
* 1-2 years case/care management experience
* Experience with all patient populations, including, Commercial,
Medicaid & Medicare
* Computer literacy: Ability to operate computer programs and work
within various documentation platforms
* Strong customer service skills to coordinate service delivery
including proactive identification and resolution of issues that
will promote positive patient outcomes
* This job requires access to confidential and sensitive
information, requiring ongoing discretion and secure information
* 9 Holiday + 1 Floating Holiday
* 403b Retirement Plan
* Medical / Vision / Dental (if eligible)
Keywords: Legacy Community Health, Houston , RN Care Manager - Case Management, Executive , Houston, Texas
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