Texas Health Resources CARE MGR RN in Dallas, Texas
This position will be located in Plano, Frisco, Richardson area.
The Care Manager – Registered Nurse is responsible for managing Population Health Service Company (PHSC) primary care population for PCP, Post-Acute, and Home Health high risk and/or chronic illness patients via creation of pro-active patient centered action plans to promote effective education, self-management support, and adherence to the PCP provider’s plan of care facilitating access and timely healthcare delivery to achieve cost effective optimal quality and financial outcomes.
Minimum Education required:
Bachelor’s degree in Nursing from an accredited program, preferred
Minimum Experience required:
• Three years’ experience in care coordination, ambulatory resource management, or discharge planning with managed care population.
• Skilled nursing facility and/or home health
Completion of RN from an accredited program. Must be licensed in the state of Texas as RN and in good standing.
Valid driver's license
Skills required (if applicable):
• 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
- 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
d. Facilitate coordination of specialist utilization in collaboration with PCP
e. Perform Medication Verification for: compatibility, duplication, adherence, and cost effectiveness
f. Coordinate services with third party payers such as Transition House Calls (THC), Home Health (HH), Skilled Nursing Facility (SNF), Durable Medical Equipment (DME), Behavioral Health, and Hospice
g. Collaborate with Care Coordination team in removing barriers that prevent self-management of disease process whether social or medical. Team: Social Worker, Community Health Worker, Pharmacist, Home Health Team, Transitional Social Worker, and other ancillary team members.
h. Work with PCP and staff office daily including: staff meetings; Face to Face and impromptu visits with patients; and disease management protocols.
i. Provide 30-90 day close monitoring of High Risk and converting them to longitudinal self-management action plan.
j. Time management, organization, and flexibility a must in meeting the PCP and patient’s needs.
- 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
d. Facilitate PCP follow-up by scheduling F/U appointment directly into provider’s schedule ensuring appointment completed on same day or within 48 hours
e. Provide 30-90 day close monitoring follow-up to targeted discharged patients post-inpatient hospitalization identifying High Risk re-admission patients and converting them to longitudinal care plan for re-admission avoidance
- 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
d. Work with patients with frequent ER and Hospitalizations to reduce ER, Admissions, and Readmissions by removing barriers and using PCP more appropriately
- 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
b. Collaborate as needed with other team members to reduce/remove barriers with a goal of self-management
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.
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.