Care Manager - Ambulatory Referral Coordination (Galveston)

Minimum Qualifications:  

Bachelor's degree in nursing or related field or equivalent and two years of case management experience or four years related experience.

Licenses, Registrations, or Certifications:

Licensure as a Registered Nurse (RN)

Job Description:

To assess, counsel, educate and provide problem solving to assigned patient population. To provide timely and valid information to the interdisciplinary team, physicians and community partners related to the on-going and follow-up care of program specific chronic disease patients. Acts as an advocate for patients and coordinates and collaborates with the medical home to provide quality, cost-effective care and promote positive outcomes for all Community Health Program patients.

Job Duties: 

• Screens and/or assesses patient and/or family to determine on-going care needs, identify barriers and solutions to self management and health care access.
• Documents appropriately on all care management activities in the Pecsys medical record and other departmental databases.
• Creates an individualized care plan that addresses the patient’s disease specific educational needs and works with the patient to set self-management goals.
• Works effectively with assigned Community Health Worker to coordinate educational interventions and action plan items according to the established plan of care.
• Interacts with each patient at least monthly via telephone or in person contacts.
• Participates in activities that improve the quality and efficiency of patient care.
• Coordinates patient care throughout enrollment in the program, ensuring that plans are communicated among the medical home practitioners, ancillaries and community partners caring for the patient.
• Utilizes approved specialist referral criteria and provides necessary supporting documentation to the medical director as required for on-going specialty care needs. Coordinates specialist care via the UTMB Admissions & Financial Counseling departments.
• Enrolls patients in a timely manner based on department policy.
• Accountable for professional practice, including time management, clinical documentation, statistical and other record-keeping as needed. Reports as required to the appropriate Team Leader or designee.
• Facilitates productivity, team-building, and high team morale in the department.
• Attends educational seminars to keep abreast of current knowledge in the field of nursing, chronic disease and/or care management.
• Participates in the planning, development, implementation, and evaluation of special projects, programs, and research, as assigned.

Salary Range:  Actual salary commensurate with experience or range if discussed and approved by hiring authority.