20 days old

Care Manager RN - Registered Nurse SWHR - Collin County

Southwestern Health Resources CIN
Dallas, TX 75201
  • Job Code

Southwestern Health Resources is seeking to hire a Care Manager Registered Nurse for our Care Coordination department.

The location is Southwest Health Resources- Collin County Clinics

Salary range is $32.71/hour - Max $46.11/hour - based on relevant experience.

Work Schedule

Full Time: 40 hours per week, Monday-Friday 8:00am-5:00pm.

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. The essential job duties of this position are:

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

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


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.

Conduct patient interviews via clinic face-to-face encounters and/or telephonic contacts documenting interventions and

outcomes in PCP EMR.

Facilitate coordination of specialist utilization in collaboration with PCP.

Perform Medication Verification for: compatibility, duplication, adherence, and cost effectiveness.

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.

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.

Work with PCP and staff office daily including: staff meetings; Face to Face and impromptu visits with patients; and

disease management protocols.

Provide 30-90 day close monitoring of High Risk and converting them to longitudinal self-management action plan.

Time management, organization, and flexibility a must in meeting the PCP and patient's needs.

Perform Post-Acute patient follow up:

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

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

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.

The ideal candidate will possess the following qualifications :

Bachelor's degree nursing required.
3 years of experience in care coordination, ambulatory resource management, or discharge planning with managed care population required.
1 year skilled nursing facility, home health, education and/or case management experience strongly preferred.

Telephonic skills and disease management education a plus
RN - Registered Nurse upon hire required.
Valid Driver License required.

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.

Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.

Posted: 2019-11-24 Expires: 2019-12-23
Sponsored by:
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Care Manager RN - Registered Nurse SWHR - Collin County

Southwestern Health Resources CIN
Dallas, TX 75201

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