ACO RN Case Manager/Beneficiary Care Navigator

Hours of Work 8:00 AM-5:30 PM, Monday‑Friday. Job Overview Your role as a Beneficiary Care Navigator includes managing a caseload of individuals with moderate to severe disease acuity using data‑driven stratification. You will collaborate with clinical staff, nursing leadership, physicians, quality and IT departments to improve outcomes for patients with chronic diseases through timely, coordinated care. Responsibilities Assess barriers when a patient has not met treatment goals, is not following the care plan, or has missed important appointments. Assist patients in setting SMART goals for self‑management, teaching them how to perform self‑management tasks and reporting abnormal findings to the physician team. Collaborate with payer case managers for additional services when appropriate. Collaborate with physicians, providers, and practice staff to identify appropriate patients for care management. Collaborate with patient, physician, and other team members in assessing progress toward individual health‑care goals. Consistently document patient self‑management measures and a mutually agreed care plan, and report progress toward goals. Develop, maintain, and leverage a list of available medical supplies and community resources, fostering relationships with frequently used entities. Oversee the development, procurement, and adoption of patient self‑management educational resources used by primary clinical teams. Promote patient self‑management and empower patients/families to achieve maximum wellness independence. Provide follow‑up contact to ensure compliance with recommendations (medications, labs, specialist visits, PCP visits, dietitian, CDE, etc.). Be available to provide telephone advice per protocol, handling urgent and emergent calls. Utilize the Institute for Healthcare Improvement’s Chronic Care Model as a foundation for chronic illness care management. Perform other related duties as assigned. Qualifications Bachelor of Science in Nursing preferred or equivalent primary‑care experience with this population. Excellent communication and interpersonal skills, including oral, written, and presentation skills. Bilingual (English/Spanish) preferred. Advanced Cardiac Life Support certification preferred. Current Basic Life Support certification required. Current Texas nursing license required. #J-18808-Ljbffr 900 Methodist Corporate