Location: Galveston,TX, USA
Care Manager - Ambulatory Referral Coordination (Galveston)
**Galveston, Texas, United States**
Nursing & Care Management
UTMB Health
Requisition # 2403895
**Minimum Qualifications:**
Bachelor's degree in nursing or related field or equivalent and two years of case management experience or four years related experience.
**Licenses, Registrations, or Certifications:**
Licensure as a Registered Nurse (RN)
**Job Description:**
To assess, counsel, educate and provide problem solving to assigned patient population. To provide timely and valid information to the interdisciplinary team, physicians and community partners related to the on-going and follow-up care of program specific chronic disease patients. Acts as an advocate for patients and coordinates and collaborates with the medical home to provide quality, cost-effective care and promote positive outcomes for all Community Health Program patients.
**Job Duties:**
+ Screens and/or assesses patient and/or family to determine on-going care needs, identify barriers and solutions to self management and health care access.
+ Documents appropriately on all care management activities in the Pecsys medical record and other departmental databases.
+ Creates an individualized care plan that addresses the patient's disease specific educational needs and works with the patient to set self-management goals.
+ Works effectively with assigned Community Health Worker to coordinate educational interventions and action plan items according to the established plan of care.
+ Interacts with each patient at least monthly via telephone or in person contacts.
+ Participates in activities that improve the quality and efficiency of patient care.
+ Coordinates patient care throughout enrollment in the program, ensuring that plans are communicated among the medical home practitioners, ancillaries and community partners caring for the patient.
+ Utilizes approved specialist referral criteria and provides necessary supporting documentation to the medical director as required for on-going specialty care needs. Coordinates specialist care via the UTMB Admissions & Financial Counseling departments.
+ Enrolls patients in a timely manner based on department policy.
+ Accountable for professional practice, including time management, clinical documentation, statistical and other record-keeping as needed. Reports as required to the appropriate Team Leader or designee.
+ Facilitates productivity, team-building, and high team morale in the department.
+ Attends educational seminars to keep abreast of current knowledge in the field of nursing, chronic disease and/or care management.
+ Participates in the planning, development, implementation, and evaluation of special projects, programs, and research, as assigned.
**Salary Range:** Actual salary commensurate with experience or range if discussed and approved by hiring authority.
**Equal Employment Opportunity**
UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.
Compensation