Registered Nurse Case Manager

TX-HHSC-DSHS-DFPS•RICHMOND, TX

9d•$7,533 - $8,886•Onsite

About The Position

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage. Come work in an environment where we truly value and respect those we serve and believe in the mission that all people can achieve a higher level of wellness and independence. The state supported living centers serve people with intellectual and developmental disabilities who are medically fragile or who have behavioral problems. The centers provide campus-based direct services and supports at 13 centers located throughout the state. Learn About Our State Supported Living Centers If you are looking for a place to work where you can establish a career that is filled with purpose, this is the job for you! Free CEUs and updated resources through Lippincott access for all nurses. The RN Case Manager performs highly complex professional nursing work for individuals at the SSLC, including individuals with highly specialized medical and behavioral health needs. Provides, evaluates, and coordinates nursing care across assigned caseload. Conducts rounds in homes and infirmary areas to assess health status, review clinical information, identify trends or emerging concerns, and determine compliance with treatment plans, policies, procedures, nursing standards, and quality-of-care expectations. Completes comprehensive assessments, develops and evaluates nursing interventions and care plans, monitors and reviews case management plans and health indicators, and initiates follow-up for changes in condition, abnormal findings, medication or treatment concerns, and other clinical needs. Coordinates care with the IDT, LARs, direct care staff, nursing staff, and health care providers to support continuity of care, treatment decisions, and person-centered services. Supports admissions, transfers, medical appointments, specialized clinics, training, quality assurance reviews, policy and procedure improvement, and specialized nursing activities. Provides leadership, training, coaching, and technical assistance to nursing and direct care staff. Provides hands-on nursing care and performs highly complex and technical nursing tasks as needed. Performs related work as assigned. Works under limited supervision with considerable latitude for initiative and independent judgment. Starting salary for this position: $ 7,532.75 This position may be eligible to earn additional pay for work performed on evenings, nights and/or weekends.

Requirements

Licensed to practice as a registered nurse in the State of Texas or a state that recognizes reciprocity through the Nurse Licensure Compact.
At least one (1) year experience as a practicing registered nurse is required.
Experience in assessment and documentation of health status required.

Nice To Haves

At least two (2) years of experience as a practicing registered nurse in a health agency, hospital, or health-care facility is preferred.
Bachelor's Degree is preferred.
Previous experience working with Individuals with Intellectual and/or Developmental Disabilities (IDD) is preferred.

Responsibilities

Performs highly complex nursing case management for assigned individuals, including those with highly specialized medical and behavioral health needs.
Develops, evaluates, and monitors nursing interventions to ensure treatment plans, policies, procedures, nursing standards, and quality-of-care expectations are followed.
Conducts rounds in assigned homes and infirmary areas to assess health status, gather information from staff, identify trends or emerging concerns, and determine needed follow-up.
Reviews and monitors health indicators, care plans, and clinical records, including vital signs, weight, nutrition, symptoms, medication refusals, injuries, seizures, bowel movements, labs, consults, hospital or infirmary status, IHCPs, acute care plans, DSP instructions, physician orders, MARs, treatment records, incident reports, preventive screenings, immunizations, EKGs, psychotropic medication monitoring, and other recurring health requirements.
Uses nursing judgment to identify desired effects, side effects, contraindications, adverse reactions, and clinical trends.
Evaluates outcome, communicates concerns to the PCP and IDT and initiates appropriate follow-up.
Monitors meal and medication administration at least quarterly and documents observations in the electronic health record.
For individuals at medium or high risk for choking or aspiration, conducts meal monitoring at least monthly and documents observations related to condition, signs of illness, pain, swallowing difficulty, positioning, dining plan use, medication administration technique, and pill texture when applicable.
Responds to chronic and acute health care concerns, facilitates treatment and follow-up, communicates with the PCP, LAR, health care team, and IDT, participates in specialized clinics and consultations, provides assessment and feedback related to medical or leisure trips, completes post-hospitalization ISPA and follow-up care, maintains required training, and reports concerns to the CNE/NOO.
Performs comprehensive and highly complex physical assessments on a quarterly, annual, and as-needed basis in accordance with training and facility protocols.
Completes head-to-toe assessments, nursing reviews, annual assessments, SAMs, fall risk assessments, risk ratings, health care plan recommendations, DSP instructions, and related documentation within required timeframes.
Reviews current medical assessments, labs, consults, immunizations, diagnostic testing, meal monitoring records, medication administration observations, suction tooth brushing monitoring, and other required assessments.
Conducts appropriate screenings, recognizes signs and symptoms of illness or injury, identifies abnormal findings, determines when referrals or plan changes are needed, develops acute care plans and integrated health care plans, communicates findings to the IDT, and evaluates diagnostic information within the RN scope of practice.
Monitors assessment completed by others to ensures care provide is in compliance with policies, procedures, standards of care and quality of service.
Actively participates as the nursing expert on the individual’s interdisciplinary team (IDT), supporting proactive problem solving related to quality of care, nursing processes, and health-related concerns.
Consults with and educates IDT members, the Legally Authorized Representative (LAR), the individual, and other medical care providers about the individual’s health care plan and status.
Works to achieve consensus, coordinates with providers and staff to support continuity of care, and advocates for the individual’s needs and preferences.
Analyzes data, evaluates nursing intervention outcomes, and provides input to the IDT to support assessment of the treatment plan.
Participates in other required and assigned meetings related to individuals on the caseload, including unit, morning, IDT, ISPA, ISP, psychiatric, CLDP, admissions, critical incident, RCA, transition, committee, daily morning medical, and Incident Management Review Team (IMRT) meetings, or provides information to a designee when assigned.
Attends prepared to discuss assessments, documentation, consults, labs, clinic issues, medications, weights, diet, screenings, IHCP goals and interventions, change-of-status needs, tracking and trending information, follow-up needs, risk ratings, care plans, and recommendations.
Follows local SSLC policies and protocols to ensure pertinent information, including diagnoses and treatment plans, is clearly communicated to SSLC staff and, when instructed, to guardians or LARs.
Coordinates, organizes and leads the nursing team for the individuals on the assigned caseload.
Leads and instructs assigning nursing staff on how to best care for the individual.
Develops inservice training and health education strategies related to the assigned individuals.
Attends daily medical and other meetings to keep abreast of individuals’ health status.
Actively participates in, and prepares for in advance, essential meetings related to the individuals on the assigned caseload to manage and coordinate health care.
During morning meetings, reports relevant information from 24-hour reports, home shift logs, health concerns, clinic logs, hospital or infirmary status, medical appointments, laboratory appointments, restraints, medication or treatment refusals, injuries, falls, missed or cancelled appointments, and significant medical issues.
Updates necessary items in the automated system(s) and other tracking documents and takes the necessary action to communicate information to other disciplines.
Conducts quality assurance reviews and specialized activities related to the development, evaluation, enhancement, and refinement of nursing policy, procedure, and operations.
Reviews nursing practices to determine compliance with state and federal laws, regulations, standards, and campus requirements and to improve the quality of nursing care.
Develops, evaluates, revises, and explains policies, procedures and protocols related to nursing case management.
Assists in developing guidelines for the RNCM position.
Makes recommendations to the CNE/NOO on how to improve case management processes to ensure quality services for individuals.
Makes recommendations to nursing leadership and participates in nursing program planning, evaluation, workgroups, and committees as assigned.
Attends on-campus medical appointments, treatments, or clinics with individuals as assigned and off-campus appointments when needed to coordinate continuity of care.
Prepares and communicates relevant nursing and medical information, follows up on recommendations, orders, and plan changes, completes required nursing notes or provider communication, supports emergency room, hospital, transfer, and placement communication, and coordinates family or guardian notification and required consents for consults, procedures, vaccinations, psychotropic medications, pre-treatment sedation, and other care needs.
Determines when pre-treatment sedation may be needed for diagnostic tests or appointments and communicates with the clinic nurse or appropriate clinical staff regarding the pre-treatment care plan.
Obtains verbal consent with a nurse witness when permitted, ensures written consent is routed for original signature when required, and provides signed or verbal consent documentation to records staff for filing.
Ensures admission and transfer planning occurs in accordance with policies, procedures, and nursing best practices.
Coordinates admission activities by reviewing medical information, preparing physician order and vaccination consent information, completing baseline assessments and documentation, and participating in 30-day ISP preparation.
Coordinates transfers to another unit, RNCM, SSLC, or group home by completing nurse-to-nurse reports, communicating pending labs, diagnostics, consults, IHCP/DSP instructions, immunizations, allergies, medications, recent assessments, and other health information needed for a safe transition.
Participates in competency-based training, continuing education, and meetings to maintain competence in specialized nursing best practices, including safety, emergency procedures, CPR, infection control, confidentiality, information security, nursing case management, nursing care standards, state and federal laws, ICF/IID rules and regulations, and evidence-based practices.
Provides or supports individual-specific training for DSPs, LVNs, home staff, and receiving providers related to allergies, medications, diagnoses, chronic or acute care plans, IHCP/DSP instructions, transfers, and other health supports.
Develops, updates, reviews, and trains staff on DSP instructions.
Serves as a nursing resource for case management and, as assigned, collaborates with others to create and deliver specialized training or in-service materials.
Provides oversight, coaching, on-the-job training, and mentoring for junior or less experienced Registered Nurse Case Managers (RNCMs), Registered Nurses (RNs), and Licensed Vocational Nurses (LVNs) assigned to the care of individuals on the caseload to ensure individual health plans meet or exceed program compliance measures.
Trains RNCMs, as assigned, and serves as a resource in performing their essential job functions.
Reviews performance, supports skill development, identifies best practices in case management, and coaches staff on implementing those practices, including collaboration with other disciplines.
Provides input to the supervisor regarding nursing practices, procedures, and staff development needs.
Assists the Nurse Manager by providing leadership and oversight within the assigned home, unit, or department, including coaching and monitoring services provided by LVNs.
Acts as a preceptor for registered nurses, as assigned, and instructs new nurses on SSLC nursing functions, including acclimating them to individuals’ needs and preferences.
Serves as RNCM Supervisor in their absence, as appointed.
Completes, reviews, and maintains required nursing documentation according to daily, weekly, monthly, quarterly, annual, and event-driven schedules.
Documentation includes plans of care, assessments, nursing notes, health summaries, referrals, acute care plans, change-of-status reviews, post-hospital assessments, medication refusal follow-up, post-injury reviews, treatment/SAM records, professional oversight logs, seizure and bowel movement records, transfer reports, ISP preparation, IHCP initiation, DSP instruction updates, training records, and tracking documents for weights, vitals, labs, consults, food intake, and follow-ups.
Ensures documentation supports continuity of care, treatment decisions, regulatory compliance, and IDT planning and meets required deadlines.
Trains and coaches others to effectively use the electronic health record.
Communicates effectively, and provides consultation, training, and technical assistance to direct support professionals (DSPs) about individuals’ unique care needs.
Instructs DSPs on how to monitor individuals after a treatment or procedure using instruction sheets such as that used for post-sedation monitoring of signs and symptoms.
Answers questions from DSPs and other members of the treatment team, related to treatment or medication, within the scope of practice.
Develops in-service training and health education strategies related to the assigned individual(s) when needed including signs and symptoms to observe for and report to a nurse.
When warranted, instructs, counsels, and assists individuals in meeting their health care needs.
As needed due to staffing, complex cases, or on-the-job training, provides direct care nursing services and performs highly complex and technical nursing tasks in accordance with HHSC, SSLC, and state requirements, including tracheostomy care, gastrostomy/jejunostomy care, wound care, breathing treatments, and treatment for HHS employees injured in the course and scope of employment.
Establishes and maintains professional working relationships with persons served, co-workers, supervisors, ancillary staff, and visitors.
Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation.
Such participation may require an alternate shift pattern assignment and/or location.