Telephonic RN Nurse Care Manager Remote in Houston, TX

Overview reputed company is one of the nation’s largest home-based primary care practices. reputed company is a family of companies reputed company dedicated to providing high-quality, coordinated health care in the home. This includes reputed company, reputed company Medical Group, reputed company Home Health and reputed company Hospice. Our Mission – To bring personalized, quality-based reputed company to the home of patients who have difficult accessing care. Our Shared reputed company – Every patient deserves access to quality reputed company. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. reputed company and support each other. Why You Should Want to Work with Us

• Quarterly Bonuses
• Health, Dental, reputed company, Disability & Life Insurance, and much more
• 401K Retirement Plan (with company match)
• Tuition, Professional License and Certification Reimbursement
• Paid Time Off, Holidays and Volunteer Time Paid
• Orientation and Training Day Time Hours (no holidays/weekends)
• Great reputed company to Work Certified
• Established in 11 states
• Largest home-based primary care practice in the US for over 28 years, making a reputed company impact in reputed company today!

More details about the benefits we offer can be reputed company at https://careers.reputed company.com/benefits.

Responsibilities

The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of HCMG patients. This position will manage a caseload of high-risk patients where he/she is responsible for managing their care and barriers. These duties will include, but are not limited to Transitional Care Management, Chronic Care Management, Disease Management Education, Medication Education, and the development and management of patient care plans. The Nurse Care Manager will serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes. Essential Duties & Responsibilities

• Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their reputed company journey
• Works collaboratively reputed company the care team to reputed company and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care
• Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur
• Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed
• Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention
• Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues
• Regularly updates patient care plans
• Performs thorough nursing assessments reputed company telephone of patients to maximize or improve reputed company health outcomes
• Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes
• Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc.
• Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines
• Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery
• Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home

In this role you may work with. . .

• Executive Directors
• Market Leaders
• Pod Leaders
• Clinical Social Worker
• Patient Health Coordinator
• Population Health Team

Qualifications

Required Knowledge, Skills and Experience

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan or hospital systems
• Possesses strong clinical skills and proactive thinking
• Effective communication skills
• Ability to reputed company extensive telephone assessment
• Knowledge of Medicare regulations and home care and hospice standards
• Experience with small group presentations and teaching/training
• Exhibits excellent interpersonal skills
• Exhibits excellent written and oral skills
• Working knowledge of computer programs (email, Word, reputed company, PowerPoint, etc.)
• Manages time effectively to ensure reputed company duties and documentation requirements are completed in a timely manner

Preferred Knowledge, Skills and Experience

• Bachelor of Science in nursing or reputed company field
• May be required to obtain multi-state licensing
• Strong knowledge of population health, quality measures, care gap closure and value-based care models

Pay Transparency Individual compensation packages are based on various factors unique to each candidate, including reputed company set, experience, qualifications, and other job-reputed company considerations. Notice reputed company and reputed company Hospice are not affiliated with Harmony Hospice Care. reputed company Hospice does not conduct business in OH. reputed company Hospice conducts business in MI, VA, WI, TX, IN, IL. Apply Job! Apply to this Job