Southwestern Health Resources is seeking to hire a Care Manager Registered Nurse position for our Care Coordination department.
The location is Texas Health Fort Worth – 8150 Brooke River Drive, Dallas Texas 75247
Salary range is $32.71/hour – Max $46.11/hour – based on relevant experience.
• Full Time: 40 hours per week, Monday-Friday 8:00am-5:00pm.
The Care Manager – Registered Nurse is responsible for managing Population Health Service Company (PHSC) primary care population for PCP, Post-Acute, and Home Health high risk and/or chronic illness patients via creation of pro-active patient
centered action plans to promote effective education, self-management support, and adherence to the PCP provider's plan of care facilitating access and timely healthcare delivery to achieve cost effective optimal quality and financial outcomes. The essential job duties of this position are:
• Manage Complex High Risk (Chronically ill and/or Medically complex/fragile) patients via Longitudinal Care.
• Prioritize patients via risk stratification tool, providers referrals, inpatient/ER discharge hand offs, and departmental team
• Conduct assessments via EMR review and patient interviews for patient centered action plans that identifies and addresses
barriers to PCP plan of care adherence documenting long-term and short-term patient centered goals in EMR.
• Conduct patient interviews via clinic face-to-face encounters and/or telephonic contacts documenting interventions and
outcomes in PCP EMR.
• Facilitate coordination of specialist utilization in collaboration with PCP.
• Coordinate services with third party payers such as Transition House Calls (THC), Home Health (HH), Skilled Nursing Facility
(SNF), Durable Medical Equipment (DME), Behavioral Health, and Hospice.
• Collaborate with Care Coordination team in removing barriers that prevent self-management of disease process whether
social or medical. Team: Social Worker, Community Health Worker, Pharmacist, Home Health Team, Transitional Social
Worker, and other ancillary team members.
• Work with PCP and staff office daily including: staff meetings; Face to Face and impromptu visits with patients; and
disease management protocols.
• Provide 30-90 day close monitoring of High Risk and converting them to longitudinal self-management action plan.
• Time management, organization, and flexibility a must in meeting the PCP and patient's needs.
Perform Post-Acute patient follow up:
• Contact full admission and observation patients post discharge telephonically within 24-48 hours of discharge notification
Target ambulatory sensitive diagnoses for plan of care adherence and goal attainment:
• Work collaboratively with supporting the PHSC quality performance targets and measures addressing gaps in care and
service as it relates to care management program as outlined above.
The ideal candidate will possess the following qualifications:
• Bachelor's degree nursing required. • 3 years of experience in care coordination, ambulatory resource management, or discharge planning with managed care population required. • 1 year skilled nursing facility, home health, education and/or case management experience strongly preferred.
• Telephonic skills and disease management education a plus • RN - Registered Nurse upon hire required. • Valid Driver License required.
Skills • Practiced in and knowledge of Medicare Advantage and Commercial programs and benefits preferred.
• Chronic disease management of diverse patient populations and/or experience in health coaching.
• Excellent time management skills with ability to prioritize tasks effectively and efficiently.
Why Texas Health Resources?
Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served. Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.
At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.
Texas Health Highlights
• 2018 FORTUNE Magazine's “100 Best Companies to Work For®” (4th year in a row)
• 2018 Becker's Healthcare "150 Great Places to Work in Healthcare" (4th year in a row)
• 2018 Employees' Choice “Best Places to Work” by Glassdoor