Registered Nurse Care Manager, Supervisor - PSH

Overview

In partnership with patients, their families (as defined by the patient), and multidisciplinary teams, the Supervisor,
Registered Nurse Care Manager - Permanent Supportive Housing delivers patient-centered care coordination for
individuals requiring specialized services. The Supervisor, Registered Nurse Care Manager collaborates closely with
patients, caregivers, healthcare providers, educational systems, and interdisciplinary teams to ensure
comprehensive, integrated, and compassionate care.
This position will act as an RN Care Manager for the Permanent Supportive Housing Health Care Collaborative (PSH
HCC), supervise team members, and serve as an advisor to program managers to ensure efficient, fiscally
responsible, patient care operations and successful execution of both short- and long-term population health
goals.
Permanent Supportive Housing (PSH) is permanent housing in which housing assistance (e.g., long-term leasing or
rental assistance) and supportive services are provided to assist households with at least one member (adult or
child) with a disability in achieving housing stability.

Responsibilities

• Interacts with patients via phone calls, medical, or social services appointments, in their home in collaboration with
  another team member, community spaces on PSH properties, and other locations per program guidelines, to
  bridge the gap between systems.
• Serves as a point of contact for patients enrolling in PSH HCC.
• Collaborates with PSH HCC partners, including Integral Care, Central Health, ECHO, and PSH site case managers
  on patient-centered care.
• Coordinates and oversees implementation of program goals, processes, schedules, and standards in collaboration
  with program managers.
• Supervises Care Management team members, including hiring, onboarding, competency/quality monitoring,
  evaluations, and performance management.
• Serves as a liaison to program managers to support data engagement, population health initiatives, and valuebased
  care principles.
• Trains staff, assigns and monitors completion of tasks, and ensures all team members understand goals and
  expectations.
• Assesses learning needs, develops competency plans, and provides learning opportunities for direct reports.
• Manages scheduling for Care Management staff; oversees timekeeping, time-off requests, and staffing levels.
• Oversees daily staff activities and provides support for day-to-day questions.
• Leads team huddles.
• Manages escalated patient issues using a Trauma-Informed Care approach and provides direction and follow-up to
  staff and care teams.
• Compiles data for departmental and program reporting.
• Reviews staff work for accuracy, evaluates performance, and provides coaching as needed.
• Implements corrective actions, including coaching, disciplinary steps, demotion, or termination when necessary.
• Participates in quality initiatives to ensure compliance with evidence-based guidelines and improve patient
  outcomes.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and
  families, as well as appropriate use of resources.
• Empowers patients and/or their families to be engaged and active participants in their care management.
• Performs thorough biopsychosocial assessments with patients and their families to identify care needs, strengths,
  and potential barriers to optimal health outcomes.
• Develops a comprehensive care plan in collaboration with patients, families, and the primary care team.
• Continuously monitors patients' biopsychosocial needs and provides timely follow-up in alignment with program
  protocols to ensure continuity of care and support.
• Coordinates transitions between sites and providers of care.
• Provides education and guidance to patients and their families to support understanding of health conditions,
  promote self-management, and enhance overall well-being.
• Coordinates and streamlines patient referrals to appropriate community-based services, ensuring timely access to
  resources that support health, wellness, and social needs.
• Delivers direct nursing care in alignment with program protocols, including executing standing delegation orders
  and administering medications and treatments in accordance with established standards of practice.
• Performs patient triage by assessing clinical and psychosocial needs to prioritize care and ensure timely
  intervention and appropriate resource allocation.
• Accurately completes all documentation related to direct and indirect patient care in a timely manner, ensuring
  that medical records are up-to-date, thorough, and compliant with organizational standards.
• Plays an active role in daily unit-based patient care huddles and periodic clinic-wide informational meetings,patient conferences, and planning sessions. These engagements support quality assurance initiatives, care
  coordination, and continuous improvement in patient services.
• Participates in ongoing professional development through seminars and educational sessions, ensuring compliance
  with all licensure and certification requirements while staying current with best practices in the field.
• Participates in the implementation and evaluation of quality improvement strategies to ensure compliance with
  evidence-based guidelines and standards, while identifying opportunities to enhance patient outcomes and care
  delivery.
• Ensures all tasks provided and associated with patient care, patient administrative processes, and related duties
  comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare
• Policies and Procedures.
• Cultivates and sustains positive working relationships and strategic partnerships with colleagues across
  departments-including leaders, support staff, providers, and other personnel. Communicates effectively with all
  members of the care team to deliver patient-centered, coordinated care.
• Engages respectfully and collaboratively with patients and their families, utilizing a trauma-informed care approach
  to foster trust and build positive, supportive relationships.
• Performs any other duties as needed to drive the vision, fulfill the mission, and abide by the values of this
  organization.

Qualifications

Education:

• Associate's Degree - Graduation from an accredited school of nursing [Required]
• Bachelor's Degree - Bachelor of Science in Nursing (BSN) [Preferred]

Experience:

• Three (3) years of clinical nursing experience [Required]
• Four (4) years of clinical nursing experience [Preferred]
• One (1) year of experience providing Care/Case Management services [Preferred]
• One (1) year of experience providing care to individuals experiencing homelessness [Preferred]
• Lead/supervisor experience [Preferred]

Licenses & Certifications:

• Active, unrestricted Registered Nurse License in the State of Texas or Compact State Licensure [Required]
• Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current CPR certification during
  employment [Required]
• Valid Texas Driver's License [Required]