RN Case/Care Manager

CenterWell • Floresville, TX

8d • Hybrid

About The Position

Become a part of our caring community and help us put health first The Role Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated. This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications. This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Requirements

• Unrestricted Registered Nurse (RN license) in the state of Texas
• Minimum of 4 years of experience working in human services and navigating community-based resources
• Advanced clinical acumen
• Ability to multi-task in a fast-paced work environment
• Flexibility to fluidly transition and adjust in an evolving role
• Excellent organizational skills
• Advanced oral and written communication skills
• Strong interpersonal and relationship building skills
• Compassion and desire to advocate for patient needs
• Critical thinking and problem-solving capabilities
• Must reside in Floresville or South San Antonio metro
• Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, incremental time may be requested to meet business needs.

Nice To Haves

• Experience working in care/case management
• Prior value-based care experience and working with complex Senior populations
• Experience working effectively within interdisciplinary teams
• Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations nor assistance

Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
• Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
• Develop care plans leveraging 5Ms Geriatric best practice framework
• Develop a wholistic view of patient needs related to Social Determinants of Health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
• Refer patient to necessary services and supports This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation
• Lead Interdisciplinary Team Meetings when indicated
• Assess patient’s family system, and conduct family meetings with patient and family when needed
• Participate in creation and facilitation of team training content
• Conduct group psychoeducation and support groups within the Center
• Perform all other duties and responsibilities as required
• Participate in and lead interdisciplinary review of and coordination around complex patients
• Maintain patient confidentiality in accordance with HIPAA
• Document patient encounters in medical record system in a timely manner
• Follow general policies related to fire safety, infection control and attendance

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed