Registered Nurse Case Manager

Location: Richmond, TX

About the Role

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. The state supported living centers serve people with intellectual and developmental disabilities who are medically fragile or who have behavioral problems. The centers provide campus-based direct services and supports at 13 centers located throughout the state.

If you are looking for a place to work where you can establish a career that is filled with purpose, this is the job for you! Free CEUs and updated resources through Lippincott access for all nurses.

The RN Case Manager performs highly complex professional nursing work for individuals at the SSLC, including individuals with highly specialized medical and behavioral health needs. Provides, evaluates, and coordinates nursing care across assigned caseload. Works under limited supervision with considerable latitude for initiative and independent judgment.

Responsibilities

• Performs highly complex nursing case management for assigned individuals, including those with highly specialized medical and behavioral health needs.
• Develops, evaluates, and monitors nursing interventions to ensure treatment plans, policies, procedures, nursing standards, and quality-of-care expectations are followed.
• Conducts rounds in assigned homes and infirmary areas to assess health status, gather information from staff, identify trends or emerging concerns, and determine needed follow-up.
• Reviews and monitors health indicators, care plans, and clinical records, including vital signs, weight, nutrition, symptoms, medication refusals, injuries, seizures, bowel movements, labs, consults, hospital or infirmary status, IHCPs, acute care plans, DSP instructions, physician orders, MARs, treatment records, incident reports, preventive screenings, immunizations, EKGs, psychotropic medication monitoring, and other recurring health requirements.
• Uses nursing judgment to identify desired effects, side effects, contraindications, adverse reactions, and clinical trends. Evaluates outcomes, communicates concerns to the PCP and IDT, and initiates appropriate follow-up.
• Monitors meal and medication administration at least quarterly and documents observations in the electronic health record. For individuals at medium or high risk for choking or aspiration, conducts meal monitoring at least monthly and documents observations related to condition, signs of illness, pain, coughing, swallowing difficulty, positioning, dining plan use, medication administration technique, and pill texture when applicable.
• Responds to chronic and acute health care concerns, facilitates treatment and follow-up, communicates with the PCP, LAR, health care team, and IDT, participates in specialized clinics and consultations, provides assessment and feedback related to medical or leisure trips, completes post-hospitalization ISPA and follow-up care, maintains required training, and reports concerns to the CNE/NOO.
• Performs comprehensive and highly complex physical assessments on a quarterly, annual, and as-needed basis in accordance with training and facility protocols. Completes head-to-toe assessments, nursing reviews, annual assessments, SAMs, fall risk assessments, risk ratings, health care plan recommendations, DSP instructions, and related documentation within required timeframes.
• Reviews current medical assessments, labs, consults, immunizations, diagnostic testing, meal monitoring records, medication administration observations, suction tooth brushing monitoring, and other required assessments.
• Conducts appropriate screenings, recognizes signs and symptoms of illness or injury, identifies abnormal findings, determines when referrals or plan changes are needed, develops acute care plans and integrated health care plans, communicates findings to the IDT, and evaluates diagnostic information within the RN scope of practice.
• Monitors assessments completed by others to ensure care provided is in compliance with policies, procedures, standards of care, and quality of service.
• Actively participates as the nursing expert on the individual’s interdisciplinary team (IDT), supporting proactive problem solving related to quality of care, nursing processes, and health-related concerns.
• Consults with and educates IDT members, the Legally Authorized Representative (LAR), the individual, and other medical care providers about the individual’s health care plan and status.
• Works to achieve consensus, coordinates with providers and staff to support continuity of care, and advocates for the individual’s needs and preferences.
• Analyzes data, evaluates nursing intervention outcomes, and provides input to the IDT to support assessment of the treatment plan.
• Participates in other required and assigned meetings related to individuals on the caseload, including unit, morning, IDT, ISPA, ISP, psychiatric, CLDP, admissions, critical incident, RCA, transition, committee, daily morning medical, and Incident Management Review Team (IMRT) meetings, or provides information to a designee when assigned.
• Attends prepared to discuss assessments, documentation, consults, labs, clinic issues, medications, weights, diet, screenings, IHCP goals and interventions, change-of-status needs, tracking and trending information, follow-up needs, risk ratings, care plans, and recommendations.
• Follows local SSLC policies and protocols to ensure pertinent information, including diagnoses and treatment plans, is clearly communicated to SSLC staff and, when instructed, to guardians or LARs.
• Coordinates, organizes, and leads the nursing team for the individuals on the assigned caseload. Leads and instructs assigning nursing staff on how to best care for the individual.
• Develops in-service training and health education strategies related to the assigned individuals.
• Attends daily medical and other meetings to keep abreast of individuals’ health status. Actively participates in, and prepares for in advance, essential meetings related to the individuals on the assigned caseload to manage and coordinate health care.
• During morning meetings, reports relevant information from 24-hour reports, home shift logs, health concerns, clinic logs, hospital or infirmary status, medical appointments, laboratory appointments, restraints, medication or treatment refusals, injuries, falls, missed or cancelled appointments, and significant medical issues.
• Updates necessary items in the automated system(s) and other tracking documents and takes the necessary action to communicate information to other disciplines.
• Conducts quality assurance reviews and specialized activities related to the development, evaluation, enhancement, and refinement of nursing policy, procedure, and operations.
• Reviews nursing practices to determine compliance with state and federal laws, regulations, standards, and campus requirements and to improve the quality of nursing care.
• Develops, evaluates, revises, and explains policies, procedures, and protocols related to nursing case management. Assists in developing guidelines for the RNCM position.
• Makes recommendations to the CNE/NOO on how to improve case management processes to ensure quality services for individuals. Makes recommendations to nursing leadership and participates in nursing program planning, evaluation, workgroups, and committees as assigned.
• Attends on-campus medical appointments, treatments, or clinics with individuals as assigned and off-campus appointments when needed to coordinate continuity of care.
• Prepares and communicates relevant nursing and medical information, follows up on recommendations, orders, and plan changes, completes required nursing notes or provider communication, supports emergency room, hospital, transfer, and placement communication, and coordinates family or guardian notification and required consents for consults, procedures, vaccinations, psychotropic medications, pre-treatment sedation, and other care needs.
• Determines when pre-treatment sedation may be needed for diagnostic tests or appointments and communicates with the clinic nurse or appropriate clinical staff regarding the pre-treatment care plan.
• Obtains verbal consent with a nurse witness when permitted, ensures written consent is routed for original signature when required, and provides signed or verbal consent documentation to records staff for filing.
• Ensures admission and transfer planning occurs in accordance with policies, procedures, and nursing best practices. Coordinates admission activities by reviewing medical information, preparing physician order and vaccination consent information, completing baseline assessments and documentation, and participating in 30-day ISP preparation.
• Coordinates transfers to another unit, RNCM, SSLC, or group home by completing nurse-to-nurse reports, communicating pending labs, diagnostic testing, and other pertinent information.
• May serve in an on-call status on a rotating schedule as required to meet operational needs of the facility.

Requirements

• Attends work on a regular basis and may be required to work a specific shift schedule or, at times, even a rotating schedule, extended shift, and/or overtime in accordance with agency leave policy and performs other duties as assigned.
• Graduation from an accredited four-year college or university with a Bachelor’s degree in Nursing, or from an accredited three-year school of professional nursing, or from an accredited school of vocational nursing plus two years of professional nursing experience.
• Current license to practice professional nursing in Texas or a state that recognizes reciprocity through the Nurse Licensure Compact.
• Experience in nursing, preferably in a long-term care, intellectual/developmental disabilities, or related healthcare setting.

Benefits

Our comprehensive benefits package includes:

• 100% paid employee health insurance for full-time eligible employees.
• A defined benefit pension plan.
• Generous time off benefits.
• Numerous opportunities for career advancement.

Explore more details on the Benefits of Working at HHS webpage.

Pay

Salary Range: $7,532.75 - $8,886.16 per month.

Starting salary for this position: $7,532.75.

This position may be eligible to earn additional pay for work performed on evenings, nights, and/or weekends.

Schedule

• Shift: Day (First shift).
• Full-time position.
• Not eligible for telework.
• Travel: Up to 5%.
• Regular/Temporary: Regular.