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.

 

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.

Compensation