Experienced RN, Care Manager

Responsibilities Collaborate with multidisciplinary team members to address unmet needs of assigned patient populations. Conduct telephonic outreach and home/virtual visits based on patient acuity and care requirements. Perform comprehensive health risk and disease management assessments, including psycho-social care needs. Deliver outreach, education, and interventions to patients with high utilization patterns to prevent avoidable hospital admissions. Develop patient-centered care plans in partnership with patients and the care team. Coordinate services with primary care teams, specialists, home care providers, hospital teams, and managed care organizations. Monitor patient progression toward goals and adjust care plans as needed to ensure success. Identify and address barriers to meeting goals, adhering to treatment plans, or keeping appointments. Build collaborative relationships with patients to promote disease prevention and health self-management. Participate in caseload rounds and consultations with the care team to ensure optimal care delivery. Assist patients in obtaining medical supplies and referrals for additional education or services. Maintain accurate and timely medical documentation of care management activities in the designated care management module. Adhere to assigned caseloads, timeframes, and Legacy Community Health safety reporting guidelines. Contribute to refining and developing new standards of work to enhance care quality. Manage caseloads effectively to reduce avoidable ER visits, hospital admissions, and readmissions. Attend staff meetings and participate in ongoing educational opportunities to enhance your skills. Perform other duties as assigned to support the overall mission of Legacy Community Health. Qualifications Registered Nurse with an active, unrestricted Texas licensure. Must maintain BLS/CPR. State Board recognized nursing education. 3‑5 years acute clinical experience. 1‑2 years case/care management experience. Case Management Certification. Motivational interviewing experience. Experience with all patient populations, including commercial, Medicaid, and Medicare. Computer literacy: Ability to operate computer programs and work within various documentation platforms. Strong customer service skills to coordinate service delivery including proactive identification and resolution of issues that will promote positive patient outcomes. Handling confidential and sensitive information requires ongoing discretion and secure information management. Federally Qualified Health Clinic (FQHC) experience. Bilingual (Spanish). Ability to think critically and problem solve. #J-18808-Ljbffr Jobtailor