RN Care Manager

Benefits Paid Time Off & Paid Company HolidaysMedical, Dental, Vision & Life InsuranceFlexible Spending Account (FSA)403(b) Retirement Plan with Company MatchShort-Term & Long-Term Disability$0 Copay for Legacy Provider visits$0 Copay for prescriptions filled at Legacy PharmaciesTravel Insurance & Pet InsuranceSubsidized Gym MembershipAnd much more! Apply today in less than 3 minutes using your phone, tablet, or computer! Location: Legacy Montrose Allen Parkway - 2929 Allen Pkwy. Houston, TX 77019 RN Care Manager - Job Overview Schedule: Monday-Friday (8AM-4:30PM or 8:30AM-5PM) Join our family as an RN Care Manager and bring your nursing expertise, compassion, and passion for relationship-based care to patients with complex health and social needs. As an integral member of the Care Team, you will coordinate holistic care for high-risk, emerging high-risk, high-utilizer, and chronic illness patients while helping them move toward healthier, more independent lives. You will assess, plan, implement, monitor, and evaluate the services each patient needs. By building trusting relationships and partnering across the healthcare system, you will help patients access timely care, understand their care plans, strengthen self-management skills, and overcome barriers that may otherwise contribute to avoidable emergency room visits or hospital admissions. Why This Role Matters Make a meaningful difference in community healthcare by supporting patients with complex medical and social needsPartner with a multidisciplinary team to create patient-centered care plans and coordinate services across the healthcare systemUse education, self-management support, and compassionate outreach to help patients take an active role in their healthContribute to improved clinical outcomes while helping prevent avoidable emergency room visits, hospital admissions, and readmissionsContinue growing through team consultations, education offerings, and opportunities to refine or develop standards of work Your Impact And Team Experience You will work closely with primary care teams, specialists, home care providers, hospital teams, managed care organizations, patients, and other partners involved in care delivery. Together, you will identify unmet needs, coordinate practical resources, and adjust interventions as patients progress toward their goals. Build collaborative relationships that support meaningful, patient-centered outcomesHelp patients navigate an often-complex healthcare ecosystem with confidence and dignityContribute your perspective during team consultations, education opportunities, and evolving standards of workFind purpose in nursing care that strengthens both individual well-being and community health If you are passionate about helping people overcome barriers to care and want your work to have a lasting impact, this role offers meaningful opportunities to make a difference while growing alongside a dedicated team. Key Responsibilities Work in collaboration with multidisciplinary team members to address the unmet needs of the assigned populationComplete telephonic outreach and home/virtual visits as applicable, based on patient acuityPerform comprehensive health risk assessment/disease management assessment that is consistent with the patient’s complex chronic/co-morbid condition(s)Identify psycho-social care needs as part of comprehensive patient assessmentsProvide outreach, education, and interventions for patients who have excessive utilization patterns, where usual care management approaches have been ineffective in preventing avoidable admissions to the Emergency Room and Inpatient settingsCollaborate with the patient and care team to develop a patient-centered care planCoordinate services with the patient’s care team, including the primary care team, specialists, home care, hospital team, managed care organization, and any others involved with the patient’s care to optimize clinical outcomesRoutinely assess patient progression toward goals and adjust interventions as neededAssess barriers when a patient has not met stated goals, is not following the treatment plan of care, or has not kept important appointments; facilitate appropriate resources/referrals as neededCreate a collaborative relationship with the patient in the management of their healthcare status through education plans related to health preservation, disease prevention, and disease self-management interventionsParticipate in regularly scheduled caseload rounds/consultations with the care team, focusing on patients who are newly assigned to the caseload or who are not improving as anticipatedRefer patients to other entities for education as neededAssist patients with the procurement of medical supplies when necessaryMaintain required medical documentation for care management activities in the designated care management moduleFollow standards of work and consistently maintain department-established caseloads and timeframes for case completionDocument and report all quality and patient safety events by recording and adhering to all of Legacy Community Health’s safety reporting guidelinesParticipate in the refinement and/or development of new standards of workMaintain awareness of key performance indicators/metrics and manage caseloads through coordinating interventions to prevent avoidable ER visits, hospital admissions, and readmissionsAttend staff meetings and education offerings both in person and via teleconference/online as requiredPerform all other duties as assigned Minimum Qualifications Registered Nurse with an active, unrestricted Texas licensureMust maintain BLS/CPRState Board recognized nursing education Required Years Of Experience 3-5 years acute clinical experience1-2 years case/care management experience Desirable Education And/or Experience Case Management CertificationMotivational interviewing Required Knowledge, Skills, And/or Abilities Experience with all patient populations, including, Commercial, Medicaid & MedicareComputer literacy: Ability to operate computer programs and work within various documentation platformsStrong customer service skills to coordinate service delivery including proactive identification and resolution of issues that will promote positive patient outcomesThis job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management Desirable Knowledge, Skills, And/or Abilities Federally Qualified Health Clinic (FQHC) experienceBilingual (Spanish)Ability to think critically and problem solve About Legacy Community Health The largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has delivered affordable, high-quality care for nearly 40 years across 50+ clinics in Greater Houston and the Gulf Coast. Our mission — driving healthy change in our communities — guides everything we do, and it starts with our people. Approachable & Collaborative — Leads with humility, values diverse perspectives, and builds trust through teamwork. Driven & Committed — Takes initiative and goes the extra mile to improve patient outcomes and drive continuous improvement. Thoughtful Communicators — Pairs clinical/technical skill with emotional intelligence, navigating complex situations with empathy and professionalism. #INDLP1