Care Manager RN - FT Days - THPG
Dallas, TX US
Area of Interest:
Texas Health Organization for Physicians
The Care Manager – Registered Nurse is responsible for managing Texas Health Physician Group's primary care population for high risk and/or chronic illness patients via creation of pro-active care 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 Care Manager will be assigned to 5-6 PCP clinics in the North Zone working in the Grapevine, Southlake, Trophy Club, Coppell areas with expectation to travel to one each day.
Required Minimum Education-
Bachelor's degree in related field preferred.
Required Minimum Experience-
Three years in care coordinator, ambulatory resource management, or discharge planning with
managed care population.
Skilled nursing facility and/or home health experience a plus.
RN License -Completion of RN from an accredited program. Must be licensed in the state of Texas
and be in good standing.
Valid Driver's License
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 High Risk (Chronically ill and/or Medically complex/fragile) patients via Longitudinal Care
a. Prioritize patients via risk stratification tool, providers referrals, inpatient discharge hand offs, and departmental team referrals.
b. Conduct assessments via EMR review and patient interviews for care plan that identifies and addresses barriers to PCP plan of care adherence documenting 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), Social Worker Consult (SW), Skilled Nursing Facility (SNF), Durable Medical Equipment (DME), and Hospice.
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 with-in same day and/or 48 hour touch back.
e. Provide 30 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 the Clinical Documentation Specialists supporting the THPG 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 specific action plans, and/or care plan adjustment.
Collaborate as needed with other team members for clinical and social aspects of patient case promoting team citizenship. 5%
Texas Health Organization for Physicians (THOP) is Texas Health Resources' 501(a) not-for-profit health corporation offering employment opportunities for administration staff that service providers of Texas Health Physicians Group (THPG). THOP provides services for member physicians that help them get back to what they do best -- practice medicine. From an affordable electronic medical record to comprehensive practice support services and group purchasing power, physicians and their patients benefit from being a part of THPG.