Nurse Care Manager

4 months ago

Houston, United States Su Vida Services Inc Full time
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
What You'll Do

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. 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:

Responsibilities
  • Oversees 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 Bring

Experience, Knowledge, Skills, and Abilities
  • Minimum 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 Requirements
  • Bachelor'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.

  • Nursing Care Specialist

    4 weeks ago

    Houston, Texas, United States Res-Care, Inc Full time

    Nursing Care SpecialistResCare Community Living is seeking a compassionate and skilled Nursing Care Specialist to join our team of dedicated professionals. Our nursing group focuses on delivering exceptional patient care and meeting the unique needs of our clients in various settings.Key Responsibilities:Assess health problems and needs of individuals...

  • Graduate Nurse Medical Care

    2 weeks ago

    Houston, United States Fresenius Medical Care North America Full time

    Supports FMCNA's mission, vision, core values and customer service philosophy. Adheres to the FVC/FMCNA Compliance Program, including following all regulatory and FVC/FMS policy requirements. Provides direct nursing care pre, during and post procedure, under the direction of the Facility Manager and/or Charge Registered Nurse, utilizing standard nursing...

  • RN - ICU/Critical Care - Travel - Houston, TX - Excellent Benefits

    4 weeks ago

    Houston, United States Travel Nurse Source Full time

    TravelNurseSource is working with Cynet Health to find a qualified ICU/Critical Care RN in Houston, Texas, 77030 About The Position Job Title: Registered Nurse (RN) Job Specialty: Surgical Intensive Care Unit (SICU) Job Duration: 13 weeks Shift: 12-Hour Nights Guaranteed Hours: 36 hours per week Experience: Minimum of 2 years License: Required...

  • RN Care Manager

    2 weeks ago

    Houston, United States carefor Full time

    RN Care Manager - Houston AreaJob Summary CareFor is currently looking for a Bachelor's prepared RN to join our Care Management team in a full-time capacity. Nurses who do well in our environment have experience with developing long-term relationships with patients (and their support network ' children, siblings, spouses, close friends) and enjoy caring for...

  • RN Care Manager

    2 months ago

    houston, United States carefor Full time

    RN Care Manager - Houston AreaJob Summary CareFor is currently looking for a Bachelor's prepared RN to join our Care Management team in a full-time capacity. Nurses who do well in our environment have experience with developing long-term relationships with patients (and their support network ' children, siblings, spouses, close friends) and enjoy caring for...

  • Home Health Care Nurse

    1 month ago

    Houston, Texas, United States Family Tree Private Care Full time

    Family Tree Private Care is a leading provider of concierge-level home care services to older adults and those living with disabilities.We are seeking a compassionate and experienced Registered Nurse to join our team and provide high-quality care to our patients in the comfort of their own homes.The ideal candidate will have a strong passion for service,...

  • PRN Clinical Nurse Care Manager I

    2 weeks ago

    Houston, United States Harris Health System Full time

    The Clinical Nurse Care Manager (CNCM I) position supports the healthcare team in transitional care by being a liaison between patients, their families, doctors, and health care providers. CNCM I facilitates transitional care, with the underlying obj Clinical, Care Manager, RN, Nurse, Manager, Medical Equipment, Healthcare

  • Geriatric RN Medical Care Manager

    6 days ago

    Houston, United States AIDS Healthcare Foundation Full time

    body>Geriatric RN Medical Care ManagerWHO WE ARE AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!If so, AIDS Healthcare Foundation is the place for you!Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and...

  • Geriatric RN Medical Care Manager

    4 weeks ago

    houston, United States AIDS Healthcare Foundation Full time

    Geriatric RN Medical Care ManagerWHO WE ARE AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!Does the idea of doing something that really makes a difference in people's lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its...

  • Nurse Practitioner

    4 weeks ago

    Houston, Texas, United States Frontier Direct Care Full time

    Transform Healthcare and Deliver Exceptional Patient OutcomesAt Frontier Health, we're revolutionizing the patient care experience. Our streamlined direct care process empowers Nurse Practitioners to focus on what matters most: delivering compassionate, high-quality care to our members.What You'll Be Doing Provide exceptional medical care to our members...

  • Senior LTSS Service Care Manager

    2 months ago

    houston, United States Centene Corporation Full time

    Senior LTSS Service Care Manager (RN)You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. Travel RN LTSS Care - Must reside...

  • ER Nurse Manager

    2 weeks ago

    Houston, Texas, United States Village Emergency Room Llc Full time

    Job OverviewWe are seeking an ER Nurse Manager to lead our emergency department team.The successful candidate will be responsible for providing high-quality patient care, managing clinical operations, and collaborating with interdisciplinary teams.

  • Case Manager

    2 weeks ago

    Houston, United States Texas Children's Hospital Full time

    Case Manager (RN) for Care Coordination - Health PlanWe are searching for a Case Manager (RN - Road Warrior) for Care Coordination - Health Plan - someone who will utilize a collaborative approach, asses, plan, implement, monitor and evaluate the options and services required to meet an individual's health needs. This nurse will provide comprehensive ongoing...

  • Case Manager

    3 weeks ago

    houston, United States Texas Children's Hospital Full time

    Case Manager (RN) for Care Coordination - Health PlanWe are searching for a Case Manager (RN - Road Warrior) for Care Coordination - Health Plan - someone who will utilize a collaborative approach, asses, plan, implement, monitor and evaluate the options and services required to meet an individual's health needs. This nurse will provide comprehensive ongoing...

  • Senior Staff Registered Nurse

    5 months ago

    Houston, United States Houston Methodist Primary Care Group Full time

    At Houston Methodist, the Sr Staff Registered Nurse (RN) position is responsible for functioning as an advanced clinician at the Proficient level according to Benner's model of clinical practice. The Sr Staff RN position provides professional direct patient nursing care to a diverse patient population, which may include patients with varied and complex...

  • Senior Staff Registered Nurse

    2 days ago

    Houston, United States Houston Methodist Primary Care Group Full time

    At Houston Methodist, the Sr Staff Registered Nurse (RN) position is responsible for functioning as an advanced clinician at the Proficient level according to Benner's model of clinical practice. The Sr Staff RN position provides professional direct patient nursing care to a diverse patient population, which may include patients with varied and complex...

  • Senior Staff Registered Nurse

    1 month ago

    Houston, United States Houston Methodist Primary Care Group Full time

    At Houston Methodist, the Sr Staff Registered Nurse (RN) position is responsible for functioning as an advanced clinician at the Proficient level according to Benner's model of clinical practice. The Sr Staff RN position provides professional direct patient nursing care to a diverse patient population, which may include patients with varied and complex...

  • RN Clinical Care Manager

    3 weeks ago

    Houston, United States Medix Full time

    Job DescriptionJob DescriptionJob Summary: We’re looking for Nurse Care Managers for our Care and Case Management team, who are passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions.  The telephonic Nurse Care Manager will guide members through complex medical and...

  • Dialysis Program Manager Registered Nurse

    1 month ago

    Houston, United States Fresenius Medical Care Holdings, Inc. Full time

    Covering 4 clinics (can be housed out of any of the 4 locations) Northside Champions – Nov 2024 Oak Ridge – Early 2025 Conrow – Jan 2025 PURPOSE AND SCOPE: Manages patient care in home therapies programs while maintaining cost-effective clinical operations. Provides direction and guidance to the interdisciplinary team providing care to the Home...

  • LVN In-Home Care

    4 weeks ago

    Houston, United States Family Tree Private Care Full time

    Description:Family Tree Private Care is a leading and trusted provider of concierge-level advisory services to older adults, those living with disabilities, and their families. Family Tree Private Care is an ideal fit if you are looking for a fulfilling opportunity, passionate teammates, and a growing company to help support your career. The Company is based...