Nurse Care Manager (3835)
About The Position
Coordinate and manage care for high-risk patients to improve outcomes and minimize hospital utilization. Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals. Identify and address gaps in patient care through proactive outreach and follow-up services. Implement standing delegated orders and management protocols. Facilitate and participate in Annual Wellness Visits. Participate in or lead regular Care Team meetings. Serve as a liaison between primary care, specialty providers, and behavioral health services for coordinated patient treatment plans. Offer education and coaching (based on WFM guidelines) to patients on self-management for chronic conditions. Conduct comprehensive assessments of patients' physical, mental, and psychosocial needs, accordant to WFM training and certification. Develop individualized care plans focusing on disease prevention and self-care improvement. Assist patients in navigating the healthcare system, coordinating specialty care and follow-up on test results. Provide direct nursing care as needed. As assigned by supervisor.
Requirements
- LVN or Certified Medical Assistant certification
- Two years of direct patient care
- Apply case management, disease management, and patient education skills.
- Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients.
- Proficiency in assessment, problem identification, and care plan development.
- Professional interaction skills with physicians and healthcare professionals.
- Working knowledge of physical and behavioral health medications.
- Skilled in conducting health assessments and screenings.
- Familiarity with behavioral strategies, including motivational interviewing.
- Proficient in written and oral communication skills.
- Possess a valid Texas driver’s license and appropriate liability insurance
- Access to personal transportation
- Visual and auditory accuracy
- Indoor setting
- Continuous use of computer
- Long periods of sitting
- Frequent use of telephone and/or smart devices
- Continuous repetitive grasping and manipulation of both hands
- Continuous conversational communication
- Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing
- Occasionally carrying, lifting, pushing and pulling of up to 25 lbs.
- Occasionally working in confined, noisy, dusty areas
- Understand/carry out simple/detailed, oral/written instructions
- Memorize and retain instructions
- Read and interpret detailed specifications
- Mental competency
- Tobacco non-user
Nice To Haves
- Five years of direct patient care
- Experience in case management, disease management, and patient education
- Bilingual
Responsibilities
- Coordinate and manage care for high-risk patients to improve outcomes and minimize hospital utilization.
- Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals.
- Identify and address gaps in patient care through proactive outreach and follow-up services.
- Implement standing delegated orders and management protocols.
- Facilitate and participate in Annual Wellness Visits.
- Participate in or lead regular Care Team meetings.
- Serve as a liaison between primary care, specialty providers, and behavioral health services for coordinated patient treatment plans.
- Offer education and coaching (based on WFM guidelines) to patients on self-management for chronic conditions.
- Conduct comprehensive assessments of patients' physical, mental, and psychosocial needs, accordant to WFM training and certification.
- Develop individualized care plans focusing on disease prevention and self-care improvement.
- Assist patients in navigating the healthcare system, coordinating specialty care and follow-up on test results.
- Provide direct nursing care as needed.
- As assigned by supervisor.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
