Nurse Care Manager

Who We AreAt 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 UniqueWe 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 WorkOur Culture & Core BeliefsEarn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving ForwardWhat You'll Do Position SummaryThe 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. This 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. They will also oversee transitions of care for patients to ensure safe transitions from acute to post-acute care, by coordinating timely and cost-effective care. The Nurse Care Manager will oversee highly complex and resource intense patients within their assigned care team. They will collaborate with all providers, care team, patients, caregivers, payers, community resources, and external providers to promote quality of care. Essential responsibilities consist of but are not all inclusive: ResponsibilitiesOversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers. Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans. Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions. Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility. Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Coordinates/facilitates patient care progression throughout the continuum. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitors 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; facilitates the following on a timely basis: completion and reporting diagnostic testing, treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communicates relative information to the care team; assignment of appropriate levels of care; completion of all required documentation.Coordinates and communicates with providers and all involved care team members in the discharge plan to ensure their participation and readiness. Ensures that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care. Knowledgeable of the Four Elements of the Coleman Model Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies. Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge. Schedules patient for follow up with PCP or specialist within 7 days of discharge. Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge. Reviews and evaluates patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions. Tracks and monitors readmissions to acute care facilities and assists with re-hospitalization reduction initiatives. Works with clinical team to establish care programs to help prevent readmissions and hospitalizations. Obtains patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Refers cases, issues to clinical leadership team, and follows up as indicated. Refers appropriate cases for social work intervention as needed. Collaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment, and supplies. Actively participates in clinical performance improvement activities. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data. Collects, analyzes, and addresses variances from the plan of care with multidisciplinary care team. Documents assessments, phone calls, and patient interactions in the Electronic Medical Record promptly. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. Other duties as assigned that are within the nurse's scope of practice. What You'll BringExperience, Knowledge, Skills, and AbilitiesMinimum 2 years of experience as a Registered Nurse Minimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or another 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, as evidenced by 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 in the center full time. Education, Licensure, or Certification RequirementsBachelor's degree in nursing or healthcare related field Master's Preferred Active Texas or Multi-state Compact Registered Nurse License 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.