US Heart & Vascular
Location
Irving, Texas
The Care Manager provides telephonic and in-person coordination for patients with chronic cardiovascular diseases, focusing on chronic and transitional care management. Responsibilities include patient outreach, education, monitoring diagnostics, and collaborating with a multidisciplinary medical team.
Candidates must hold at least an associate degree in nursing and a valid RN license for Texas or specific compact states. BLS certification and competence in cardiovascular technology and CMS documentation guidelines are required.
The Care Manager will perform telephonic Chronic Care Management, Principal Care Management, Remote Patient Monitoring and Transitional Care Management services to coordinate care for patients with chronic cardiovascular diseases and manage their post-acute care. Responsibilities & Duties: Under the general guidance of nurse manager, practice physicians and advanced practice providers, the RN is primarily responsible for the following: Outreaching referred and eligible patients to introduce care management services, obtain verbal consent for enrollment, and document in EHR per standard operating procedures Make outgoing calls to patients to assist patients in managing their chronic diseases - including education about their conditions and treatment regimens, medication management, appointment management Coordinates care across the continuum for patients with chronic cardiovascular conditions in collaboration with primary cardiologist, advanced practice providers, and other members of the multidisciplinary team within outpatient clinic setting Assesses patient health and SDOH need, documenting and implementing care plans that optimize health outcomes Serves as an important liaison for the interdisciplinary team and community organizations inclusive of other inpatient and outpatient care delivery organizations Provide patient-and-family-centered-care in the outpatient setting and telehealth setting, including triaging calls and patient messages in the EHR Provides patient and caregiver education related to health conditions, patient care, transitions of care, and ongoing chronic care management Evaluates remote patient monitoring technology, diagnostics, and laboratory results to engage advanced practice provider for appropriate patient care and interventions Ensures all CMS documentation and billing guidelines are adhered to in EHR Requirements: Requires excellent clinical, communication and organizational skills Requires multitasking and critical analysis Must be able to function independently within the limits of the position Ability to function in a team environment Demonstrate knowledge and competence in care management inclusive of transitional care management and complex care management Demonstrate knowledge and competence in basic cardiovascular technology, i.e., EKG, patient assessment and management of care, labs/hospital test results Strong understanding of population health concepts and clinical documentation requirements Able to demonstrate interpersonal skills to be approachable and understandable to patients, families, and care team members Minimum of an associate's degree in nursing; graduate of an accredited nursing program. Currently licensed to practice as registered nurse with a compact license or licensure for Alabama, Arizona, Kansas, Louisiana, and Texas Current BLS for Healthcare Providers certification About Dallas/Fort Worth, TX: Dallas/Fort Worth, known as the Metroplex, offers a vibrant urban life and peaceful suburban living, making it an enticing place to reside. Spanning across ten major cities and thirteen counties, it stands as the largest metroplex in the south. With its extensive range of recreational parks, renowned dining scene, five professional sports teams to root for, and two bustling airports facilitating over 2,000 daily flights, Dallas/Fort Worth provides residents with a multitude of reasons to consider it an excellent place to call home. Qualifications
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