RN Care Manager

Legacy Community Health•Houston, TX

2d•Onsite

About The Position

Join our family as an RN Care Manager and bring your nursing expertise, compassion, and passion for relationship-based care to patients with complex health and social needs. As an integral member of the Care Team, you will coordinate holistic care for high-risk, emerging high-risk, high-utilizer, and chronic illness patients while helping them move toward healthier, more independent lives. You will assess, plan, implement, monitor, and evaluate the services each patient needs. By building trusting relationships and partnering across the healthcare system, you will help patients access timely care, understand their care plans, strengthen self-management skills, and overcome barriers that may otherwise contribute to avoidable emergency room visits or hospital admissions. Make a meaningful difference in community healthcare by supporting patients with complex medical and social needs. Partner with a multidisciplinary team to create patient-centered care plans and coordinate services across the healthcare system. Use education, self-management support, and compassionate outreach to help patients take an active role in their health. Contribute to improved clinical outcomes while helping prevent avoidable emergency room visits, hospital admissions, and readmissions. Continue growing through team consultations, education offerings, and opportunities to refine or develop standards of work. You will work closely with primary care teams, specialists, home care providers, hospital teams, managed care organizations, patients, and other partners involved in care delivery. Together, you will identify unmet needs, coordinate practical resources, and adjust interventions as patients progress toward their goals. Build collaborative relationships that support meaningful, patient-centered outcomes. Help patients navigate an often-complex healthcare ecosystem with confidence and dignity. Contribute your perspective during team consultations, education opportunities, and evolving standards of work. Find purpose in nursing care that strengthens both individual well-being and community health. If you are passionate about helping people overcome barriers to care and want your work to have a lasting impact, this role offers meaningful opportunities to make a difference while growing alongside a dedicated team.

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
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

Nice To Haves

Case Management Certification
Motivational interviewing
Federally Qualified Health Clinic (FQHC) experience
Bilingual (Spanish)
Ability to think critically and problem solve

Responsibilities

Work in collaboration with multidisciplinary team members to address the unmet needs of the assigned population.
Complete telephonic outreach and home/virtual visits as applicable, based on patient acuity.
Perform comprehensive health risk assessment/disease management assessment that is consistent with the patient’s complex chronic/co-morbid condition(s).
Identify psycho-social care needs as part of comprehensive patient assessments.
Provide outreach, education, and interventions for patients who have excessive utilization patterns, where usual care management approaches have been ineffective in preventing avoidable admissions to the Emergency Room and Inpatient settings.
Collaborate with the patient and care team to develop a patient-centered care plan.
Coordinate services with the patient’s care team, including the primary care team, specialists, home care, hospital team, managed care organization, and any others involved with the patient’s care to optimize clinical outcomes.
Routinely assess patient progression toward goals and adjust interventions as needed.
Assess barriers when a patient has not met stated goals, is not following the treatment plan of care, or has not kept important appointments; facilitate appropriate resources/referrals as needed.
Create a collaborative relationship with the patient in the management of their healthcare status through education plans related to health preservation, disease prevention, and disease self-management interventions.
Participate in regularly scheduled caseload rounds/consultations with the care team, focusing on patients who are newly assigned to the caseload or who are not improving as anticipated.
Refer patients to other entities for education as needed.
Assist patients with the procurement of medical supplies when necessary.
Maintain required medical documentation for care management activities in the designated care management module.
Follow standards of work and consistently maintain department-established caseloads and timeframes for case completion.
Document and report all quality and patient safety events by recording and adhering to all of Legacy Community Health’s safety reporting guidelines.
Participate in the refinement and/or development of new standards of work.
Maintain awareness of key performance indicators/metrics and manage caseloads through coordinating interventions to prevent avoidable ER visits, hospital admissions, and readmissions.
Attend staff meetings and education offerings both in person and via teleconference/online as required.
Perform all other duties as assigned.