Nurse Care Manager

Nurse Care Manager

Suvida Healthcare LLC – Houston, Texas, United States

Who We Are

At Suvida Healthcare, we are not just caregivers; we are compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well‑being of an underserved community and their families. Our multi‑disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare‑eligible Hispanic seniors.

We celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service‑centered, and more compassionate healthcare family and Employer of Choice.

The Nurse Care Manager works with Suvida Healthcare’s multidisciplinary care team to provide high quality care for our high‑risk patients. They collaborate with the neighborhood center care team to develop organization‑wide approaches to problem‑solving, tracking, and managing complex cases and populations. This role requires effective planning to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient resource use.

The Nurse Care Manager implements Suvida’s care pathways for patients with chronic conditions and oversees transitions of care to ensure safe transitions from acute to post‑acute settings, coordinating timely and cost‑effective care. They manage highly complex and resource‑intensive patients within their assigned care team.

They collaborate with all providers, care team members, patients, caregivers, payers, community resources, and external providers to promote quality of care. Essential responsibilities include:

• Oversee chronic care and transitions of care management of high‑risk patients within their care teams and neighborhood centers.
• Serve as a resource to the multidisciplinary team for the management of complex patients, including chronic care management assessments and care plans.
• Perform triage for patients via phone and address issues appropriately or forward to the appropriate party for further interventions.
• Ensure efficient, organized patient transitions from acute and post‑acute settings to home or other transitional care facilities.
• Perform comprehensive assessments for physical, mental, and social risk factors that support individual patient needs while identifying and addressing barriers.
• Collaborate with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Coordinate/facilitate patient care progression throughout the continuum.
• Collaborate with the physician and all members of the multidisciplinary team to facilitate care for designated patients; monitor the patient’s progress, intervening as necessary to ensure that the plan of care and services provided are patient‑focused, high quality, efficient, and cost effective.
• Facilitate completion and reporting of diagnostic testing, treatment plan and discharge plan; modify the plan of care as necessary to meet ongoing patient needs; communicate relevant information to the care team; assign appropriate levels of care; complete all required documentation.
• Coordinate and communicate with providers and all involved care team members in the discharge plan to ensure participation and readiness.
• Ensure that all elements critical to the plan of care, including discharge plans, have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Be knowledgeable of the Four Elements of the Coleman Model; coordinate post‑discharge needs with providers such as durable medical equipment, home health needs, medications, and other supplies.
• Proactively identify and resolve issues impeding diagnostic, treatment progress, and discharge.
• Schedule…