RN Field Case Manager, NE Houston, TX (Hybrid)

Optum • Houston, TX

443d

About The Position

The Care Coach Connect RN/Case Manager at WellMed is responsible for coordinating care and conducting ongoing nursing assessments for patients and their families. This role emphasizes telephonic communication and home visits, ensuring that patients receive optimal medical care in their homes while collaborating with an interdisciplinary team. The position requires a strong focus on patient needs, chronic illness management, and effective communication with caregivers and healthcare providers.

Requirements

• Registered Nurse with a current license to practice in Texas.
• Current BLS certification or must obtain certification within 30 days of employment.
• 3+ years of experience in a physician's office, clinical, hospice, or hospital setting.
• Demonstrated excellent nursing skills.
• Proven excellent verbal and written communication skills.
• Ability to interact productively with individuals and multidisciplinary teams.
• Proficient computer skills, including Microsoft Word, Excel, Access, and Outlook.
• Excellent organizational and prioritization skills.
• Valid driver's license within the state of work.
• Access to reliable transportation for daily travel to various locations assigned.
• Tuberculosis screening and proof of immunity to certain diseases.

Nice To Haves

• Hospice and Palliative Care Nursing certification.
• 2+ years of hospice experience.
• Experience with home visits.
• Proven knowledge of palliative and hospice medicine.
• Experience related to advanced care planning and discussions with patients regarding end-of-life wishes.
• Experience with community-based nursing.
• Bilingual (English/Spanish) language proficiency.

Responsibilities

• Conducts medical home visits on established Care Coach Connect patients performing a hands-on exam at each visit.
• Conducts urgent/acute visits on established Care Coach Connect patients to keep them out of the hospital.
• Provides ongoing assessments of the impact of life-limiting and/or chronic illnesses on the patient's needs.
• Assesses for caregiver burnout and provides community resources when appropriate.
• Implements the individualized plan of care and recommends revisions as necessary.
• Performs procedures including wound care, phlebotomy, and injections.
• Conducts advanced care discussions with patients and families, documenting their wishes in the electronic medical record.
• Consults and educates patients/families on disease processes, pain management, and end-of-life care.
• Initiates appropriate preventive and rehabilitative nursing procedures when necessary.
• Ensures continual assessment of patient and family needs throughout the course of care.
• Evaluates patient and family/caregiver responses to care and recommends alterations to the plan when necessary.
• Attends interdisciplinary meetings and actively participates as a team member.
• Solves problems by gathering facts and selecting the best solution from identified alternatives.
• Conducts telephonic nursing follow-ups and case management when necessary.
• Serves as a resource or consultant for LVN/MA.
• Attends educational offerings to stay updated on chronic medical conditions and licensing requirements.
• Establishes trusting relationships with patients, caregivers, and clinic staff.
• Collaborates with providers to recommend policies and procedures affecting patient care.
• Documents progress toward established goals in the electronic health record.
• Maintains a patient case load and meets documentation standards.

Benefits

• Opportunities for professional development and career growth.
• Supportive work environment focused on patient care and teamwork.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: No Education Listed