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RN Job In Fort Worth, Texas

Care Manager RN SWHR

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Company: Texas Health Resources Profession/Specialty: RN Social WorkerPsychologist Location: Fort Worth, Texas 76104
Job Description

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

The location is 900 Jerome St, Fort Worth Texas 76104

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

Work Schedule
• Full Time – Days

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 functions for 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 referrals.

Perform Post-Acute patient follow up.

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

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.

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.

• Performs other duties as assigned.



The ideal candidate will possess the following qualifications:

Bachelor's Degree Nursing from an accredited program required

3 Years Experience in care coordination, ambulatory resource management, or discharge planning with managed care population required.

Skilled nursing facility and/or home health experience preferred.

RN - Registered Nurse Completion of RN from an accredited program. Must be licensed in the state of Texas and be in good standing Upon Hire Required.

DL - Drivers License Must be valid. Upon Hire Required.

Skills

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 a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.

EOE
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