Nurse Care Manager

Suvida Healthcare LLC; Tucson (AZ); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Competitive pay

Medical & Dental Coverage

Paid Time Off

Job summary

Suvida Healthcare LLC in Tucson, AZ is seeking a Nurse Care Manager to join our multidisciplinary team and guide high‑risk patients through chronic care management and transitions of care. You will collaborate with clinicians to develop organization‑wide approaches to problem solving, track complex cases, and promote efficient utilization of resources.

The Nurse Care Manager will oversee transitions of care, coordinate with physicians, and ensure patient‑focused, high‑quality, cost‑effective

Qualifications

• Minimum 2 years' RN experience in case management or discharge planning.
• Strong interpersonal and negotiation skills.
• Bilingual English/Spanish preferred.

Responsibilities

• Oversee chronic care and transitions of care for high‑risk patients.
• Coordinate and communicate with care team and providers.
• Perform triage for patients by phone and route to appropriate interventions.
• Ensure smooth transitions from acute to post‑acute care.
• Document assessments and care plans in the EMR.

Skills

RN experience

Utilization management

Chronic care management

Discharge planning

Transitions of care

Data analysis

EMR systems

Microsoft Office

Bilingual English/Spanish

Education

Multi-state Compact RN Licensure

Tools

EMR systems

Microsoft Office Suite

Job description

About this position

At Suvida Healthcare, we are not just caregivers; we’re 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.

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! Will you join us Suvidanos, to help achieve our Higher Purpose?

What Makes Us Unique

We are an empowered primary care team, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well‑being of the seniors we serve.

How We Work

Our Culture & Core Beliefs: Earn Trust, Building Relationships, Creating Joy, Doing Right, Improving Every Day, Moving Forward

Our Promise

Purpose Driven Career, Competitive Pay, Best‑In‑Class Medical/Dental Coverage, Free Mental Health & Life Coaching for Team Members and their Dependents, Holiday Time Off with Pay, Paid Community Service Day, Paid Parental/Family Leave, Paid Bereavement Leave, Generous Paid Time Off (PTO), 401k Retirement Plan with Company Match, and much more…

What You’ll Do

Position Summary

The Nurse Care Manager will work with Suvida Healthcare’s multidisciplinary care team to provide high quality care for our high‑risk patients. They will collaborate with their multidisciplinary neighborhood center care team to develop organization‑wide approaches to problem solving, tracking, and managing complex cases and populations. This nurse will need to plan effectively in order to meet patient needs, identify social determinants of health, manage chronic conditions, and promote efficient utilization of resources.

The Nurse Care Manager will implement Suvida’s care pathways for patients with chronic conditions. They will also oversee transitions of care for patients to ensure safe transitions from acute to post‑acute care by coordinating timely and cost‑effective care. The Nurse Care Manager will oversee highly complex and resource‑intensive patients within their assigned care team.

They will collaborate with all providers, care team, patients, caregivers, payers, community resources, and external providers to promote quality of care.

Responsibilities

• 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 message to appropriate parties 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, intervene as necessary, and 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 plan of care as needed.
• 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 their 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.
• Knowledgeable of the Coleman Model’s Four Elements.
• 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 patient for follow‑up with PCP or specialist within 7 days of discharge.
• Reconcile discharge medication and work with PCP and clinical pharmacist for review post‑discharge.
• Review and evaluate patient to ensure that the patient meets criteria for home health admission or admission to other transitional care institutions.
• Track and monitor readmissions to acute care facilities and assist with rehospitalization reduction initiatives.
• Work with clinical team to establish care programs to prevent readmissions and hospitalizations.
• Obtain patient medical records from acute care facilities, including orders, referrals, care team documentation, diagnostic testing results, and acute care visit summaries.
• Utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Identify at‑risk populations using approved screening tools and follow established reporting procedures.
• Refer cases and issues to the clinical leadership team and follow up as indicated.
• Refer appropriate cases for social work intervention as needed.
• Collaborate/communicate with external case managers.
• Initiate and facilitate referrals for home health care, hospice, medical equipment and supplies.
• Actively participate in clinical performance improvement activities.
• Use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data.
• Collect, analyze, and address variances from the plan of care with multidisciplinary care team.
• Document assessments, phone calls, and patient interactions in the Electronic Medical Record in a timely manner.
• Promote individual professional growth and development by meeting requirements for mandatory/continuing education and skill competency.
• Other duties as assigned within the nurse’s scope of practice.

What You’ll Bring

Knowledge, Skills, and Abilities

• Minimum 2 years of experience as a Registered Nurse.
• Minimum 2 years of experience in utilization management, case management, chronic care management, discharge planning, transitions of care management, cost/quality management program, and/or other related fields.
• Available to work during assigned clinic business hours.
• Current working knowledge of chronic care management, discharge planning, utilization management, case management, performance improvement, and/or managed care reimbursement.
• Competency in chronic care management, pre‑acute, and post‑acute venues of care, and post‑acute community resources.
• Excellent interpersonal communication, leadership, collaboration, and negotiation skills.
• Effective oral and written communication skills.
• Strong technical skills including data analysis and management, competency in Microsoft Office suite, and Electronic Medical Records.
• Strong organizational and time‑management skills, evidenced by capacity to prioritize multiple tasks and role components.
• Ability to work independently and exercise sound judgment in interactions with providers, payors, patients, and their families.
• Experience with Medicare Advantage, Value‑based care, and/or Managed Care desirable.
• Bilingual/Bicultural (English and Spanish) preferred.
• Ability to work in the center full‑time.

Education, Experience, Licensure, or Certification Requirements

Active Multi‑state Compact Registered Nurse License.

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.