DISEASE MANAGEMENT NURSE

BC&L INC•Austin, TX

1d•$88,000 - $95,000

About The Position

The Disease Management RN is a clinically strong, relationship-driven nurse coach responsible for engaging members with polymorbid, progressive, and high-risk conditions that drive avoidable utilization and high-cost claims—especially cardiac, renal (CKD), oncology, and MSK/pain-related conditions: diabetes, heart disease, obesity, nicotine use, sedentary lifestyles and more. This role is not “check-in and document.” It is targeted behavior change work: building trust, driving adherence, closing care gaps, coordinating care, and reducing preventable ED visits, admissions, complications, and inappropriate site-of-care. You will be measured by your ability to: Engage hard-to-reach members and sustain participation over time Drive behavior change using Nurse Coaching and Motivational Interviewing (MI) Improve clinical and functional outcomes (symptom control, self-management, adherence) Reduce avoidable utilization and total cost of care while improving member experience Identify rising risk early and escalate appropriately (case management, UR, complex care, behavioral health, palliative as appropriate)

Requirements

Clinically strong
Relationship-driven
Engage hard-to-reach members and sustain participation over time
Drive behavior change using Nurse Coaching and Motivational Interviewing (MI)
Improve clinical and functional outcomes (symptom control, self-management, adherence)
Reduce avoidable utilization and total cost of care while improving member experience
Identify rising risk early and escalate appropriately (case management, UR, complex care, behavioral health, palliative as appropriate)
High engagement skills with persistent outreach, rapport building, cultural humility and trust-based communication
Use Motivational Interviewing, stages of change, and coaching techniques to move members from awareness to action
Address barriers to care: health literacy, cultural considerations, transportation, affordability, SDOH, caregiver constraints
Provide evidence-based education that members can actually use (meds, diet, activity, symptom monitoring, red flags)
High-Cost, Multiple Condition Management (Polymorbid Focus) with strong clinical assessment and triage judgment – especially for progressive disease trajectory
Recognize deterioration early and escalate to higher-acuity programs (Complex CM, BH, specialty programs)
Coordinate with PCPs, specialists, facilities, pharmacy, behavioral health, and internal teams (Care Navigation, UR, Claims, PBM partners)
Support members in accessing high-quality, cost-effective care and appropriate site of service with our Care Navigation team
Close gaps in care and support preventive screenings and chronic condition monitoring
Document all encounters accurately in the care management platform; maintain clear problem lists, goals, interventions, and outcomes
Use data (claims, risk flags, pharmacy patterns, labs when available) to prioritize outreach and personalize care
Create and contribute to outcomes reporting and ROI narratives for employer groups and internal leadership
Document and maintain accurate records of patient care, condition, progress, and concerns.

Responsibilities

Conduct telephonic/video DM assessments; build a personalized, member-centered care plan with measurable goals
High engagement skills with persistent outreach, rapport building, cultural humility and trust-based communication. Use Motivational Interviewing, stages of change, and coaching techniques to move members from awareness to action
Address barriers to care: health literacy, cultural considerations, transportation, affordability, SDOH, caregiver constraints
Provide evidence-based education that members can actually use (meds, diet, activity, symptom monitoring, red flags)
High-Cost, Multiple Condition Management (Polymorbid Focus) with strong clinical assessment and triage judgment – especially for progressive disease trajectory. Cardiac: CHF, CAD, HTN, hyperlipidemia—support medication adherence, symptom surveillance, lifestyle coaching, follow-up cadence Renal: CKD risk reduction, BP/diabetes optimization, nephrology alignment, labs monitoring, avoidance of nephrotoxins, dialysis prevention readiness when applicable Oncology: supportive care coaching, adherence support, side-effect triage guidance, coordination with oncology team, avoidable ER mitigation
Recognize deterioration early and escalate to higher-acuity programs (Complex CM, BH, specialty programs)
Coordinate with PCPs, specialists, facilities, pharmacy, behavioral health, and internal teams (Care Navigation, UR, Claims, PBM partners)
Support members in accessing high-quality, cost-effective care and appropriate site of service with our Care Navigation team
Close gaps in care and support preventive screenings and chronic condition monitoring
Document all encounters accurately in the care management platform; maintain clear problem lists, goals, interventions, and outcomes
Use data (claims, risk flags, pharmacy patterns, labs when available) to prioritize outreach and personalize care
Create and contribute to outcomes reporting and ROI narratives for employer groups and internal leadership
Document and maintain accurate records of patient care, condition, progress, and concerns.
Performs other duties as assigned.