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RN Care Management - Med Surg

Company: Legacy Community Health
Location: Houston
Posted on: November 20, 2023

Job Description:

RN Care ManagementLegacy 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.

Job Description

The RN Care Manager (CM) is an integral member of the Care Team. This role is 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 delivery.

Essential Functions

* 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 as needed.
* 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 needed.
* 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 self-management interventions.
* 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 necessary.
* 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 reporting guidelines.
* 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

Work Experience

* 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 management
* Ability to meet Legacy Community Healths EPIC proficiency requirements


As part of values that Healthcare is a Right and not a Privilege, we offer a suite of benefits

* Medical / Vision / Dental (Costs of benefits are based on your yearly salary)
* Medical visit copays are waived when seeing a Legacy provider.

* 9 Holiday + 1 Floating Holiday
* 403b Retirement Plan
* Bright Horizons Back-up Care
* As a user of Bright Horizons Back-Up Care, you can conveniently schedule care right from your mobile device with the Back-Up Care app your easy, time-saving solution to managing family care challenges while on the go.

* Paid Time Off (PTO)
* PTO Exchange benefit

PTO Exchange will provide you with the option to convert a portion of your accrued but unused PTO hours for use toward several different benefits and causes, based on your own priorities.

With PTO Exchange, you can convert a portion of your unused PTO into:

* 403(b) Retirement contributions
* Student loan payments / Tuition for the employee
* Leave Sharing donations to fellow employees

Keywords: Legacy Community Health, Houston , RN Care Management - Med Surg, Executive , Houston, Texas

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