Care Coach Connect RN Case Manager - Lubbock or Abilene, TX

About the position

The Care Coach Connect RN Case Manager at WellMed is responsible for coordinating care and conducting nursing assessments for patients, primarily through home visits and telephonic case management. This role involves working closely with interdisciplinary teams to implement and evaluate individualized care plans, ensuring that patients receive optimal care in their homes. The position emphasizes the importance of community health and aims to keep patients out of the hospital by providing necessary support and resources.

Responsibilities

• Conducts medical home visits on established Care Coach Connect patients performing a hands-on exam at each visit
• Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital
• Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patient's needs
• Assesses for caregiver burnout and provides community resources when appropriate
• Implements the individualized plan of care and recommends revisions as necessary
• Performs procedures including wound care, phlebotomy, and injections
• Conducts advanced care discussions with patients and families, documenting their wishes
• Consults and educates patients/families regarding disease processes and end-of-life care
• Initiates appropriate preventive and rehabilitative nursing procedures
• Ensures continual assessment of patient and family needs throughout the course of care
• Evaluates patient and family/caregiver response to care and recommends alterations to the plan when necessary
• Attends interdisciplinary meetings and contributes as a vocal team member
• Solves problems by gathering facts and selecting the best solution
• Conducts telephonic nursing follow-up and case management when necessary
• Serves as a resource for LVN/MA
• Attends educational offerings to stay updated on chronic medical conditions
• Establishes trusting relationships with patients, caregivers, and clinic staff
• Collaborates with providers to recommend policies affecting patient care
• Exhibits professionalism and courtesy with all patients and staff
• Informs providers of patient needs and outcomes of interventions
• Coordinates patient/family services and prioritization of needs with the interdisciplinary team
• Documents progress toward established goals in the electronic health record
• Maintains a patient case load and point of care documentation levels as per standards
• Performs all other related nursing duties as assigned

Requirements

• Registered Nurse with a current license to practice in the state of employment
• Current BLS certification or must obtain certification within 30 days of employment
• 3+ years of experience in a physician's office, clinical, hospice or hospital setting
• Demonstrated experience of excellent nursing skills
• Proficient computer skills, including Microsoft Word, Excel, Access and Outlook
• Demonstrated ability to interact productively with individuals and multidisciplinary teams
• Reliable transportation for daily travel to various locations, up to 80% of the time
• Valid driver's license within the state of work

Nice-to-haves

• Hospice and Palliative Care Nursing certification
• 2+ years of hospice experience
• Experience with home visits
• Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
• Experience with community-based nursing
• Knowledge of palliative and hospice medicine
• Bilingual (English/Spanish) language proficiency
• Proven excellent verbal and written skills
• Proven excellent organizational and prioritization skills

Benefits

• Competitive salary
• Comprehensive health insurance
• 401(k) retirement plan
• Paid time off and holidays
• Continuing education opportunities
• Supportive work environment focused on diversity and inclusion