RN Case/Care Manager

apartment Conviva Senior Primary Care location_onFloresville, TX 78114, US

Become a part of our caring community and help us put health first

The Role

Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated.

This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications.

This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Major Duties and Responsibilities

Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
Develop care plans leveraging 5Ms Geriatric best practice framework
Develop a wholistic view of patient needs related to Social Determinants of Health
Identify existing barriers to engagement with necessary resources and supports
Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
Refer patient to necessary services and supports
- This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation
Lead Interdisciplinary Team Meetings when indicated
Assess patient’s family system, and conduct family meetings with patient and family when needed
Participate in creation and facilitation of team training content
Conduct group psychoeducation and support groups within the Center
Perform all other duties and responsibilities as required
Participate in and lead interdisciplinary review of and coordination around complex patients
Maintain patient confidentiality in accordance with HIPAA
Document patient encounters in medical record system in a timely manner
Follow general policies related to fire safety, infection control and attendance

Use your skills to make an impact

Required Qualifications

Unrestricted Registered Nurse (RN license) in the state of Texas
Minimum of 4 years of experience working in human services and navigating community-based resources

Preferred Qualifications

Experience working in care/case management
Prior value-based care experience and working with complex Senior populations
Experience working effectively within interdisciplinary teams
Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations nor assistance

Skills/Abilities/Competencies Required

Advanced clinical acumen
Ability to multi-task in a fast-paced work environment
Flexibility to fluidly transition and adjust in an evolving role
Excellent organizational skills
Advanced oral and written communication skills
Strong interpersonal and relationship building skills
Compassion and desire to advocate for patient needs
Critical thinking and problem-solving capabilities

Working Conditions

This role has a mobile presence and requires regular onsite engagement with the care team to assigned clinics to see patients in person and collaborate with care team members.

Workstyle: Hybrid - Combination in clinic and working remotely/virtually.

Location: Must reside in Floresville or South San Antonio metro

Hours: Must be able to work a 40-hour work week, Monday through Friday 8:00 AM to 5:00 PM, incremental time may be requested to meet business needs.

Scheduled Weekly Hours

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.

About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

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