Nurse Care Manager

Nurse Care Manager Suvida Healthcare LLC – Houston, Texas, United States About this position Who We Are At Suvida Healthcare, we are not just caregivers; we are compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well‑being of an underserved community and their families. Our multi‑disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare‑eligible Hispanic seniors. We celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service‑centered, and more compassionate healthcare family and Employer of Choice. What You’ll Do Position Summary The Nurse Care Manager works with Suvida Healthcare’s multidisciplinary care team to provide high quality care for our high‑risk patients. They collaborate with the neighborhood center care team to develop organization‑wide approaches to problem‑solving, tracking, and managing complex cases and populations. This role requires effective planning to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient resource use. The Nurse Care Manager implements Suvida’s care pathways for patients with chronic conditions and oversees transitions of care to ensure safe transitions from acute to post‑acute settings, coordinating timely and cost‑effective care. They manage highly complex and resource‑intensive patients within their assigned care team. They collaborate with all providers, care team members, patients, caregivers, payers, community resources, and external providers to promote quality of care. Essential responsibilities include: Oversee chronic care and transitions of care management of high‑risk patients within their care teams and neighborhood centers. Serve as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans. Perform triage for patients via phone and address issues appropriately or forward to the appropriate party for further interventions. Ensure efficient, organized patient transitions from acute and post‑acute settings to home or other transitional care facilities. Perform comprehensive assessments for physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers. Collaborate with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Coordinate/facilitate patient care progression throughout the continuum. Collaborate with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitor the patient’s progress, intervening as necessary to ensure that the plan of care and services provided are patient‑focused, high quality, efficient, and cost effective. Facilitate completion and reporting of diagnostic testing, treatment plan and discharge plan; modify the plan of care as necessary to meet ongoing patient needs; communicate relevant information to the care team; assign appropriate levels of care; complete all required documentation. Coordinate and communicate with providers and all involved care team members in the discharge plan to ensure participation and readiness. Ensure that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care. Be knowledgeable of the Four Elements of the Coleman Model; coordinate post‑discharge needs with providers such as durable medical equipment, home health needs, medications, and other supplies. Proactively identify and resolve issues impeding diagnostic, treatment progress, and discharge. Schedule patients for follow‑up with PCP or specialist within 7 days of discharge. Reconcile discharge medication and work with PCP and clinical pharmacist for post‑discharge review. Review and evaluate patients to ensure that they meet criteria for home health admission or admission to other transitional care institutions. Track and monitor readmissions to acute care facilities and assist with re‑hospitalization reduction initiatives. Work with the clinical team to establish care programs to help prevent readmissions and hospitalizations. Obtain patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries. Utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues. Identify at‑risk populations using approved screening tools and follow established reporting procedures. Refer cases or issues to the clinical leadership team and follow up as indicated. Refer appropriate cases for social work intervention as needed. Collaborate/communicate with external case managers. Initiate and facilitate referrals for home health care, hospice, medical equipment, and supplies. Actively participate in clinical performance improvement activities. Use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data. Collect, analyze, and address variances from the plan of care with the multidisciplinary care team. Document assessments, phone calls, and patient interactions in the Electronic Medical Record promptly. Promote individual professional growth and development by meeting requirements for mandatory/continuing education and skill competency. Other duties within the nurse’s scope of practice as assigned. What You’ll Bring Experience, Knowledge, Skills, and Abilities Minimum 2 years of experience as a Registered Nurse. Minimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or another related field. Available to work during assigned clinic business hours. Current working knowledge of chronic care management, discharge planning, utilization management, case management, performance improvement, and/or managed care reimbursement. Competency in chronic care management, pre‑acute, and post‑acute venues of care, and post‑acute community resources. Excellent interpersonal communication, leadership, collaboration, and negotiation skills. Effective oral and written communication skills. Strong technical skills including data analysis and management, competency in Microsoft Office suite, and Electronic Medical Records. Strong organizational and time‑management skills, evidenced by capacity to prioritize multiple tasks and role components. Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their families. Experience with Medicare Advantage, Value‑based care, and/or Managed Care desirable. Bilingual/Bicultural (English and Spanish) preferred. Ability to work a hybrid schedule: 2 days in clinic/3 days remote. Education, Licensure, or Certification Requirements Bachelor’s degree in nursing or health care related field. Master’s degree preferred. Active Texas or multi‑state Compact Registered Nurse license. Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. #J-18808-Ljbffr