Case Management Nurse

Work Schedule: Hybrid, Monday–Friday, 8:00 AM – 5:00 PM (2–3 days onsite per week)

Employment Type: Full-Time, Direct Hire

We are seeking a dedicated Bilingual Nurse Case Manager to join our multidisciplinary outpatient care team. In this role, you will work directly with high-risk patient populations, helping to manage chronic conditions, oversee smooth transitions of care, and navigate social determinants of health. You will serve as a core advocate and strategist for complex cases, collaborating closely with primary care providers, external facilities, health plans, and community resources to ensure coordinated, high-quality care.

• Oversee chronic care management and clinical care pathways for high-risk, complex patient populations within an outpatient setting.
• Conduct comprehensive physical, mental, and social risk assessments to identify barriers to care and address social determinants of health (SDOH).
• Develop, implement, and adjust individualized care plans in collaboration with physicians, nursing staff, clinical pharmacists, and social workers.
• Perform clinical triage via phone, providing immediate guidance or routing issues to appropriate care team members.

• Facilitate seamless patient transitions from acute and post-acute settings (hospitals, SNFs) back to the home or transitional facilities.
• Apply evidence-based care transition models (such as the Coleman Model) to support patient recovery and reduce unnecessary re-hospitalizations.
• Review and reconcile post-discharge medications alongside primary care providers and clinical pharmacists.
• Coordinate essential post-discharge resources, including Home Health, Durable Medical Equipment (DME), hospice, and specialist referrals.
• Ensure primary care or specialist follow-up appointments are scheduled within 7 days of discharge.
• Obtain and review acute care records, diagnostic results, and discharge summaries to maintain continuity of care.

• Partner with payers, external case managers, and community organizations to streamline resource allocation and eliminate care delivery barriers.
• Track readmission data and participate in clinical performance improvement initiatives aimed at optimizing patient outcomes, fiscal efficiency, and patient satisfaction.
• Document all assessments, phone interactions, and care plans accurately in the Electronic Medical Record (EMR) in a timely manner.
• Utilize conflict resolution and advanced communication skills to navigate complex care scenarios and provider alignment.

• License: Active Registered Nurse (RN) License in Texas or an active Compact/Multi-State RN License (Required).
• Education: Bachelor’s Degree in Nursing (BSN), Healthcare Administration, or a related field (Preferred).

• Language: Bilingual in English and Spanish (Strongly Preferred).
• Experience: Minimum 2 years of clinical RN experience.
• Specialty
  
  Experience:
  
  Minimum 2 years in case management, chronic care management, utilization management, discharge planning, transitions of care, or value-based care programs.
• Knowledge Base: Working knowledge of managed care reimbursement, Medicare Advantage, value-based care models, and post-acute community resources.
• Technical
  
  Skills:
  
  Proficiency with Electronic Medical Record (EMR) systems and Microsoft Office Suite; comfortable using data to track care goals.
• Soft Skills: Strong clinical judgment, time management, negotiation, and cross-functional communication skills.