Nurse Care Manager (Contract)

Nurse Care Manager (Contract) Suvida Healthcare LLC — Houston, Texas, United States About this position Who We Are At Suvida Healthcare, we are not just caregivers; we’re 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. 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. Will you join us Suvidanos, to help achieve our Higher Purpose? What Makes Us Unique We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well‑being of the seniors we serve. How We Work Our Culture & Core Beliefs Earn Trust Building Relationships Creating Joy Doing Right Improving Every Day Moving Forward Position Summary The Nurse Care Manager will work with Suvida Healthcare’s multidisciplinary care team to provide high‑quality care for our high‑risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization‑wide approaches to problem solving, tracking, and managing complex cases and populations. The nurse will need to plan effectively to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient resource use. The Nurse Care Manager will implement Suvida’s care pathways for patients with chronic conditions and oversee transitions of care to ensure safe transitions from acute to post‑acute care, by coordinating timely and cost‑effective care. They will also oversee highly complex and resource‑intense patients within their assigned care team. Responsibilities 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 messages to appropriate parties 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, collaborating with the physician and all members of the multidisciplinary team to facilitate care for designated patients. Monitor the patient’s progress, intervening as necessary and appropriate 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 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 their participation and readiness. Ensure all critical elements of the plan of care, including discharge plans, are communicated to the patient/family and healthcare team and are documented 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 review post‑discharge. Review and evaluate patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions. Track and monitor readmissions to acute care facilities and assist with rehospitalization reduction initiatives. Work with 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 and issues to 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 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 skills competency. Other duties as assigned within the nurse’s scope of practice. What You’ll Bring Minimum 1 year of experience as a Registered Nurse. Minimum 1 year of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or other 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 with 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 work location 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. This is a contract role for 12 weeks* 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