**Description** **Must reside in the Dallas/ Fort Worth, TX area or be willing to relocate.** The Care Manager RN supports the patient and primary care relationship through care delivery enhancement. Primary mechanisms for this support are telephonic outreach to patients to guide them through transitions of care, care management, preventive services, and self-management. The Care Manager acts as an integral member of the Division Care Coordination team supporting Physician Services primary care providers and practices in successfully meeting quality improvement initiatives in assigned division(s). **Job Summary and Qualifications** **General** + Serves as a subject matter expert in quality and value-based care programs such as MIPS, ACOs, and payor pay-for-performance contracts. Assists in educating practice staff on quality, payor, and government program requirements + Develops professional working relationship with HCA/PSG primary care providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness + Attends learning sessions and shares information learned with team members + Assists in the development of tools, education and workflow processes to assist the division(s) in meeting CMS, ACO, documentation, and payor quality initiatives + Collaborates with interdisciplinary teams and leaders (PSG, Payer Contracting & Alignment, Quality and Payor Initiatives) to achieve the organization’s coordination of care goals, quality goals, and financial performance goals + Conducts in-person and virtual meetings with practice managers, staff, providers and managers to communicate program goals, results, and provide education + Prepares and submits minutes from all meetings, as directed + Maintains the strictest confidentiality in the areas of patient, employee, and physician relations + Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement” + Acts as a patient advocate to facilitate appropriate care management and wellness activities + Performs related work and additional duties as requested by supervisor **Care Gaps** + Monitors patient compliance with preventive screening and/or behavioral health management processes using internal and payor reporting tools + Accesses portals as necessary to prepare reports and other documents to evaluate progress and prioritize workload + Communicates via telephone and other virtual tools with patients regarding care needs, documenting communications appropriately in the electronic medical record + Prepares and maintains patient charting as needed and performs medical record reviews for payor projects + Assists in securing and submitting necessary documentation for annual patient assessment forms (PAFs) + Understands and addresses short term behavioral health care gaps as needed **Transitions of Care** + Contacts patients after an emergency department encounter or hospital discharge to identify the need for a follow-up appointment, community resource needs, etc. + Documents assessment in the medical record to support transition of care services as specified by CMS and other program requirements **Care Management** + Uses available tools to identify at-risk patients + Triages patients to determine those appropriate for medical and/or behavioral care management + Creates a care management action plan with the patient/caregiver that includes elements of self-management, as appropriate + Identifies and enrolls eligible patients in longitudinal or chronic care management for medical or behavioral health conditions + Oversees the execution of patient care plans in partnership with Care Coordinators + Facilitates specialty referrals, as appropriate, for conditions/needs managed outside the primary care realm + Documents efforts in accordance with established workflow protocols + Identifies and engages community resources to assist patients as needed **Population Health** + Assists with practice and provider empanelment processes + Schedules appointments related to preventive care, chronic disease management, and/or integrated behavioral health + Prepares and maintains care coordination reports and provides periodic updates to practice leaders and providers + Conducts wellness campaigns for targeted, focus areas **EDUCATION & EXPERIENCE** + Graduate of an accredited college of nursing + Knowledge of physician office practice operations and one (1) year of experience in a physician practice is preferred + Current licensure as an RN in the state of residence **Benefits** PM North Texas Care Coordination, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. + Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. + Free counseling services and resources for emotional, physical and financial wellbeing + 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) + Employee Stock Purchase Plan with 10% off HCA Healthcare stock + Family support through fertility and family building benefits with Progyny and adoption assistance. + Referral services for child, elder and pet care, home and auto repair, event planning and more + Consumer discounts through Abenity and Consumer Discounts + Retirement readiness, rollover assistance services and preferred banking partnerships + Education assistance (tuition, student loan, certification support, dependent scholarships) + Colleague recognition program + Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) + Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits (https://careers.hcahealthcare.com/pages/employee-benefits-and-rewards) _Note: Eligibility for benefits may vary by location._ Our teams are a committed, caring group of colleagues. Do you want to work as a(an) Care Manager RN WFH where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise! Supporting HCA Healthcare's 186 hospitals and 2,400+ sites of care, Physician Services plays a crucial role as the main entry point for patients looking for high-quality healthcare within the HCA Healthcare system. With a focus on meeting the needs of our patients at all access points, Physician Services is dedicated to implementing innovative, physician-driven, value-added solutions to assist physicians in providing high-quality, patient-centered care, aligning with our mission to care for and enhance human life. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times.  In recent years, HCA Healthcare spent an estimated $3.7 billion in costs for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Bricks and mortar do not make a hospital. People do."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Care Manager RN WFH opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. **Unlock the possibilities and apply today!** We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.