Nurse Care Manager

Nurse Care Manager

WACO FAMILY MEDICINE - 3.2

Bellmead, TX Job Details Full-time 1 day ago Qualifications Employee relationship building Driver's License Stakeholder relationship building Full Job Description

PRIMARY DUTIES

Coordinate and manage care for high-risk patients to improve outcomes and minimize hospital utilization. Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals. Identify and address gaps in patient care through proactive outreach and follow-up services. Implement standing delegated orders and management protocols. Facilitate and participate in Annual Wellness Visits. Participate in or lead regular Care Team meetings. Serve as a liaison between primary care, specialty providers, and behavioral health services for coordinated patient treatment plans. Offer education and coaching (based on WFM guidelines) to patients on self-management for chronic conditions. Conduct comprehensive assessments of patients' physical, mental, and psychosocial needs, accordant to WFM training and certification. Develop individualized care plans focusing on disease prevention and self-care improvement. Assist patients in navigating the healthcare system, coordinating specialty care and follow-up on test results.

OTHER DUTIES

Provide direct nursing care as needed. As assigned by supervisor.

EDUCATION & EXPERIENCE

LVN or Certified Medical Assistant certification Required experience: Two years of direct patient care Preferred experience: Five years of direct patient care Experience in case management, disease management, and patient education Bilingual SKILLS Apply case management, disease management, and patient education skills. Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients. Proficiency in assessment, problem identification, and care plan development. Professional interaction skills with physicians and healthcare professionals. Working knowledge of physical and behavioral health medications. Skilled in conducting health assessments and screenings. Familiarity with behavioral strategies, including motivational interviewing. Proficient in written and oral communication skills.

PHYSICAL AND MENTAL REQUIREMENTS

Possess a valid Texas driver's license and appropriate liability insurance Access to personal transportation Visual and auditory accuracy Shift length varies Indoor setting Continuous use of computer Long periods of sitting Frequent use of telephone and/or smart devices Continuous repetitive grasping and manipulation of both hands Continuous conversational communication Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing Occasionally carrying, lifting, pushing and pulling of up to 25 lbs. Occasionally working in confined, noisy, dusty areas Understand/carry out simple/detailed, oral/written instructions Memorize and retain instructions Read and interpret detailed specifications Mental competency Tobacco non-user Physical accommodations will be implemented where necessary and feasible