Registered Nurse - Care Manager

Legacy Community Health•Houston, TX

1d•Onsite

About The Position

Are you ready to make a meaningful impact on the lives of patients in our community? At Legacy Community Health, we’re more than just a healthcare provider—we’re a family committed to delivering holistic care that addresses both health and social needs. As an Registered Nurse - Care Manager, you’ll play a pivotal role in guiding high-risk, chronic illness, and emerging high-risk patients toward healthier, more fulfilling lives. Your expertise and compassion will be the cornerstone of our mission-driven care model. Why You'll Love This Role: Be at the heart of a collaborative, multidisciplinary care team dedicated to transforming lives. Build lasting, meaningful relationships with patients, empowering them to take charge of their health journeys. Enjoy a supportive and dynamic work environment that values your voice and encourages innovation. Make a real difference by reducing avoidable ER visits, hospital admissions, and readmissions. Access abundant opportunities for professional growth, mentorship, and personal development.

Requirements

Registered Nurse with an active, unrestricted Texas licensure
Must maintain BLS/CPR
State Board recognized nursing education
3-5 years acute clinical experience
1-2 years case/care management experience
Case Management Certification
Motivational interviewing
Experience with all patient populations, including, Commercial, Medicaid & Medicare
Computer literacy: Ability to operate computer programs and work within various documentation platforms
Strong customer service skills to coordinate service delivery including proactive identification and resolution of issues that will promote positive patient outcomes
This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management
Federally Qualified Health Clinic (FQHC) experience
Bilingual (Spanish)
Ability to think critically and problem solve

Responsibilities

Collaborate with multidisciplinary team members to address the unmet needs of assigned patient populations.
Conduct telephonic outreach and home/virtual visits based on patient acuity and care requirements.
Perform comprehensive health risk and disease management assessments, including psycho-social care needs.
Deliver outreach, education, and interventions to patients with high utilization patterns to prevent avoidable hospital admissions.
Develop patient-centered care plans in partnership with patients and the care team.
Coordinate services with primary care teams, specialists, home care providers, hospital teams, and managed care organizations.
Monitor patient progression toward goals and adjust care plans as needed to ensure success.
Identify and address barriers to meeting goals, adhering to treatment plans, or keeping appointments.
Build collaborative relationships with patients to promote disease prevention and health self-management.
Participate in caseload rounds and consultations with the care team to ensure optimal care delivery.
Assist patients in obtaining medical supplies and referrals for additional education or services.
Maintain accurate and timely medical documentation of care management activities in the designated care management module.
Adhere to assigned caseloads, timeframes, and Legacy Community Health safety reporting guidelines.
Contribute to refining and developing new standards of work to enhance care quality.
Manage caseloads effectively to reduce avoidable ER visits, hospital admissions, and readmissions.
Attend staff meetings and participate in ongoing educational opportunities to enhance your skills.
Perform other duties as assigned to support the overall mission of Legacy Community Health.