Nurse Case Manager

About the Role

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families.

Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors. We celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team.

Responsibilities

The Nurse Care Manager will work with Suvida Healthcare’s multidisciplinary care team to provide high quality care for our high-risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization-wide approaches to problem solving, tracking, and managing complex cases and populations.

• Plan effectively to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient utilization of resources.
• Implement Suvida’s care pathways for patients with chronic conditions.
• Oversee transitions of care for patients to ensure safe transitions from acute to post-acute care, by coordinating timely and cost-effective care.
• Oversee highly complex and resource intense patients within their assigned care team.
• Collaborate with all providers, care teams, patients, caregivers, payers, community resources, and external providers to promote quality of care.

Requirements

• Oversees chronic care and transitions of care management of high-risk patients within their care teams and neighborhood centers.
• Serves as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans.
• Performs triage for patients via phone and addresses issues appropriately or forwards message to appropriate party for further interventions.
• Responsible for ensuring efficient, organized patient transitions from acute and post-acute setting to home or other transitional care facility.
• Perform comprehensive assessments for both physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers.

Qualifications

Bachelor’s Degree in Nursing or healthcare related field, Master’s Preferred. Active Texas or Multi-state Compact Registered Nurse License.

Skills

• Knowledgeable of the Four Elements of the Coleman Model.
• Coordinates post-discharge needs with providers, such as Durable Medical Equipment, Home Health needs, medications, and other supplies.
• Proactively identifies/resolves issues impeding diagnostic, treatment progress, and discharge.
• Schedules patient for follow up with PCP or specialist within 7 days of discharge.
• Reconciles discharge medication and works with PCP and clinical pharmacist for review post-discharge.

Benefits

Suvida Healthcare offers a range of benefits, including:

• Competitive Pay.
• Best-In-Class Medical/Dental Coverage.
• Free Mental Health & Life Coaching for Team Members and their Dependents.
• Holiday Time Off with Pay.
• Paid Community Service Day.
• Paid Parental/Family Leave.
• Paid Bereavement Leave.
• Generous Paid Time Off (PTO).
• 401k Retirement Plan with Company Match.