Texas Health Resources Care Manager RN -Home Health in Arlington, Texas

Job Description

This position will be part of our Home Health Care Management team.

The role of the Home Health Care Manager RN is to 1) manage ACO patients through the continuum of the home health episode; 2) review current home health episodes for appropriateness, and; 3) facilitate supportive discharge from home health to alternative care options. The Home Health Care Manager is a centralized, office based position with work effort conducted telephonically.

Hours/Schedule: Full Time. 40 hours per week. M-F 8am-5pm.

This is an office based position with minimal local travel and will be primarily based out of our Brook River facility at the address seen below.

8150 Brookriver Drive

Dallas, TX 75247

South tower, 5th floor

There will be periodic meetings and travels to our North point location as needed.

North point

9229 Lyndon B. Johnson Fwy.

Dallas, TX 75240

Minimum Education Requirements: Associated Degree in Nursing Required. Bachelors Degree preferred.

Minimum Experience Required: 3 years of Care coordination, ambulatory resource management, or discharge planning with managed care population.

Skilled nursing facility and/or home health experience preferred.

Two or more years of Home Health experience strongly preferred*

Licenses/Certification Requirements: Must have TX Registered Nurse license and be in good standing

AND Valid Drivers License upon hire.

Skills and Abilities: • Practiced in and knowledge of Medicare Advantage and Commercial programs and benefits preferred. • Chronic disease management of diverse patient populations and/or experience in health coaching. • Excellent time management skills with ability to prioritize tasks effectively and efficiently.

Job Duties:

Manage Complex High Risk (Chronically ill and/or Medically complex/fragile) patients via Longitudinal Care:

a. Prioritize patients via risk stratification tool, providers referrals, inpatient/ER discharge hand offs, and departmental team referrals

b. Conduct assessments via EMR review and patient interviews for patient centered action plans that identifies and addresses barriers to PCP plan of care adherence documenting long-term and short-term patient centered goals in EMR

c. Conduct patient interviews via clinic face-to-face encounters and/or telephonic contacts documenting interventions and outcomes in PCP EMR

Perform Post-Acute patient follow up:

a. Contact full admission and observation patients post discharge telephonically within 24-48 hours of discharge notification

b. Provide education on newly prescribed medications and identify barriers to obtaining prescribed medications

c. Provide education on red flag signs and symptoms related to inpatient diagnoses

Target ambulatory sensitive diagnoses for plan of care adherence and goal attainment:

a. Work collaboratively with supporting the PHSC quality performance targets and measures addressing gaps in care and service as it relates to care management program as outlined above

b. Perform chronic disease self-management improving patient engagement and adherence

c. Achieve best practice patient engagement and self-management performing Shared Medical Visits, PCP practice staff team conferences, patient centered action plans, and PCP Plan of Care adjustment

Collaboration with team members for care adherence and reducing barriers to care either social or medical

a. Collaborate as needed with Social Worker for psychosocial including mental and behavioral health aspect of patient case promoting team citizenship; Advanced Care Planning; and Life Care Planning

Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served.

Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.

At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career through our accomplishments and philosophy of excellence.

Qualifications

Minimum Education Requirements: Associated Degree in Nursing Required. Bachelors Degree preferred.

Minimum Experience Required: 3 years of Care coordination, ambulatory resource management, or discharge planning with managed care population.

Skilled nursing facility and/or home health experience preferred.

Two or more years of Home Health experience strongly preferred*

Licenses/Certification Requirements: Must have TX Registered Nurse license and be in good standing

AND Valid Drivers License upon hire.

Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.