Chronic Care Manager

Houston Metro Urology PA•Houston, TX

2d•Remote

About The Position

Houston Metro Urology (HMU) is the largest single-specialty urology practice in the Greater Houston area. Our physicians specialize in general urology as well as subspecialties including incontinence, female urology, robotic and laparoscopic surgery, genitourinary cancer treatment, prostatic laser surgery, and kidney stone disease management. HMU is recognized for its advanced technology and state-of-the-art cancer treatment. The Chronic Care Manager is an integral part of our urology team, helping deliver high-value, patient-centered care through care coordination, patient engagement, and chronic disease management. This role is responsible for identifying eligible patients for Medicare Chronic Care Management (CCM) services and providing ongoing support to improve health outcomes, increase patient satisfaction, and promote continuity of care. The ideal candidate is highly organized, detail-oriented, adaptable, and passionate about helping patients successfully manage their chronic health conditions. The candidate must reside within a reasonable commuting distance to our Houston Metro Urology clinic located in ZIP code 77027.

Requirements

Minimum 2 years of direct, clinical nursing experience required.
Minimum 1 year of experience in a Care management or Care coordinator role.
Able to reliably commute to Houston for an occasional in-person meeting.
Excellent verbal and written communication skills.
Professional demeanor.
Ability to work as a member of a multidisciplinary team.
Ability to prioritize tasks.

Nice To Haves

Urology experience.
Bilingual in Spanish and/or Vietnamese

Responsibilities

Collaborate with a multidisciplinary care team and Primary Care Physicians to ensure coordinated, comprehensive patient care and avoid fragmented services.
Contribute to a positive patient experience through courteous telephone and digital interactions, accurate documentation, and timely follow-up.
Facilitate referrals and connections to community and social support resources when appropriate.
Serve as a resource to clinical teams regarding care management and patient support services.
Contact patients to support adherence to treatment plans and help identify and address barriers to care.
Partner with patients to establish health goals, action plans, and individualized care plans.
Collaborate with patients, physicians, and other care team members to monitor progress toward health goals.
Develop and maintain a strong understanding of urology conditions, treatment plans, and best practices.
Ensure effective patient outreach for recommended care and continuity of services.
Provide patient education to improve understanding of chronic conditions and encourage self-management.
Regularly attend and participate in meetings with coworkers and practice staff.
Collaborate with payer case managers and external partners to coordinate additional services when appropriate.
Maintain accurate and timely documentation of patient interactions and care management activities.
Perform all job functions in compliance with applicable federal, state, local, and company policies and procedures.