Bilingual Nurse Case Manager

Suvida Healthcare•Austin, TX

11d

About The Position

The Nurse Care Manager works with Suvida Healthcare’s multidisciplinary care team to provide high-quality care for high-risk patients. The role collaborates with the neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations. The Nurse Care Manager plans to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient use of resources. The role implements care pathways for patients with chronic conditions and oversees transitions from acute to post-acute care, coordinating timely and cost-effective services. It manages highly complex and resource-intensive patients and collaborates with providers, patients, caregivers, payers, community resources, and external providers to promote quality care. The position also coordinates care progression, discharge planning, post-discharge follow-up, and initiatives to reduce readmissions, while documenting patient assessments and interactions in the Electronic Medical Record.

Requirements

Bachelor’s degree in Nursing or a healthcare-related field.
Active Texas or Multi-state Compact Registered Nurse license.

Nice To Haves

Master’s degree preferred.

Responsibilities

Oversee chronic care and transitions-of-care management for high-risk patients within care teams and neighborhood centers.
Serve as a multidisciplinary team resource for complex patient management, including chronic care assessments and care plans.
Perform phone triage and address patient issues or forward them to the appropriate party.
Coordinate safe, timely, and organized transitions from acute and post-acute settings to home or another transitional care facility.
Assess physical, mental, and social risk factors, identify barriers, and address individual patient needs.
Collaborate with medical, nursing, and ancillary staff to remove barriers to efficient care in the appropriate setting.
Coordinate and facilitate patient care progression throughout the continuum.
Collaborate with physicians and the multidisciplinary team to monitor patient progress, intervene as appropriate, and facilitate testing, treatment and discharge planning, care-plan modifications, appropriate levels of care, communication, and documentation.
Coordinate discharge planning with providers and care team members, ensuring their participation and readiness.
Communicate and document care-plan and discharge-plan elements with patients, families, and healthcare team members to support continuity of care.
Apply knowledge of the Four Elements of the Coleman Model.
Coordinate post-discharge needs such as durable medical equipment, home health, medications, and supplies.
Proactively identify and resolve issues that impede diagnostic, treatment, or discharge progress.
Schedule follow-up with a primary care provider or specialist within seven days of discharge.
Reconcile discharge medications and coordinate post-discharge review with the primary care provider and clinical pharmacist.
Evaluate whether patients meet criteria for home health or other transitional-care institutions.
Track and monitor acute-care readmissions and support readmission-reduction initiatives.
Work with the clinical team to establish care programs that help prevent readmissions and hospitalizations.
Obtain medical records from acute-care facilities, including orders, referrals, care-team documentation, diagnostic results, and visit summaries.
Use conflict-resolution skills to support timely resolution of issues.
Identify at-risk populations using an approved screening tool and follow reporting procedures.
Refer cases and issues to clinical leadership and follow up as indicated.
Refer appropriate cases for social work intervention.
Collaborate and communicate with external case managers; initiate and facilitate referrals for home health, hospice, medical equipment, and supplies.
Participate in clinical performance-improvement activities.
Use fiscal, clinical, and patient-satisfaction data to guide decisions and performance-improvement strategies for assigned patients.
Collect, analyze, and address variances from the plan of care with the multidisciplinary team.
Document assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner.
Meet mandatory and continuing education and skills-competency requirements to support professional growth and development.
Perform other duties within the nurse’s scope of practice as assigned.