Remote Care Management Nurse

Registered Nurse (2513)
CVBC - Care Management - Irving - Irving, TX 75062
Position Type Full Time Education Level Associates Degree Category Other Positions
US Heart and Vascular is seeking a Registered Nurse Care Manager to join our In Person Value Based Care Management team in Irving, TX. The Care Manager will perform telephonic Chronic Care Management, Principal Care Management, Remote Patient Monitoring and Transitional Care Management services to coordinate care for patients with chronic cardiovascular diseases and manage their post-acute care.
Under the general guidance of nurse manager, practice physicians and advanced practice providers, the RN is primarily responsible for the following:

Outreaching referred and eligible patients to introduce care management services, obtain verbal consent for enrollment, and document in EHR per standard operating procedures
Coordinates care across the continuum for patients with chronic cardiovascular conditions in collaboration with primary cardiologist, advanced practice providers, and other members of the multidisciplinary team within outpatient clinic setting
Assesses patient health and SDOH need, documenting and implementing care plans that optimize health outcomes
Serves as an important liaison for the interdisciplinary team and community organizations inclusive of other inpatient and outpatient care delivery organizations
Provide patient-and-family-centered-care in the outpatient setting and telehealth setting, including triaging calls and patient messages in the EHR
Provides patient and caregiver education related to health conditions, patient care, transitions of care, and ongoing chronic care management
Evaluates remote patient monitoring technology, diagnostics, and laboratory results to engage advanced practice provider for appropriate patient care and interventions
Ensures all CMS documentation and billing guidelines are adhered to in EHR
Requires multitasking and critical analysis
Demonstrate knowledge and competence in care management inclusive of transitional care management and complex care management
EKG, patient assessment and management of care, labs/hospital test results
Strong understanding of population health concepts and clinical documentation requirements
Able to demonstrate interpersonal skills to be approachable and understandable to patients, families, and care team members
Minimum of an associate's degree in nursing; graduate of an accredited nursing program.
Currently licensed to practice as registered nurse with a compact license or licensure for Alabama, Arizona, Kansas, Louisiana, and Texas
Current BLS for Healthcare Providers certification
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