Onsite RN Case Manager for High-Risk Populations

Central Health; Austin (TX); On-site; USD 75,000 - 105,000; Full time

Job summary

Central Health seeks an RN Case Manager for High Risk Populations to lead multidisciplinary teams in assessing medical and social needs, delegating non-medical tasks, and ensuring timely follow-up. The role collaborates with social workers, physicians, and community partners to support patients in the High Risk Population program and improve outcomes.

The on-site position requires residing in the Austin area.

Qualifications

• Graduation from an accredited School of Nursing.
• Two years nursing experience in clinic, hospital, or related setting.
• Current unrestricted RN license to practice in Texas.

Responsibilities

• Conduct patient assessments, including home visits and shelter visits, to evaluate medical, behavioral health, functional and social needs.
• Provide rapid clinical assessment and intervention during crises and coordinate urgent services for patient safety.
• Develop culturally responsive, evidence-based care plans with measurable goals for complex patient needs.
• Facilitate seamless care across primary, specialty, dental, behavioral health, and community systems.
• Coordinate hospital referrals, discharge planning, med reconciliation, and timely appointment scheduling.
• Collaborate with PCP on medication management and education for prescribed therapies.
• Educate and empower patients to navigate the health system and promote primary and preventive care access.
• Lead the case management team and coordinate with physicians, social workers and community health workers to reduce disparities.

Skills

Critical thinking

Crisis management

Interpersonal communication

Cultural sensitivity

Care coordination

Team collaboration

Education

RN licensure in TX

Nursing degree

BLS certification

Tools

Microsoft Outlook

Excel

Job description

Central Health seeks an RN Case Manager for High Risk Populations to lead multidisciplinary teams in assessing medical and social needs, delegating non-medical tasks, and ensuring timely follow-up. The role collaborates with social workers, physicians, and community partners to support patients in the High Risk Population program and improve outcomes.

The on-site position requires residing in the Austin area.