Registered Nurse Care Manager, Supervisor - PSH

Overview

In partnership with patients, their families (as defined by the patient), and multidisciplinary teams, the Supervisor,Registered Nurse Care Manager – Permanent Supportive Housing delivers patient-centered care coordination forindividuals requiring specialized services. The Supervisor, Registered Nurse Care Manager collaborates closely withpatients, caregivers, healthcare providers, educational systems, and interdisciplinary teams to ensurecomprehensive, integrated, and compassionate care.This position will act as an RN Care Manager for the Permanent Supportive Housing Health Care Collaborative (PSHHCC), supervise team members, and serve as an advisor to program managers to ensure efficient, fiscallyresponsible, patient care operations and successful execution of both short- and long-term population healthgoals.Permanent Supportive Housing (PSH) is permanent housing in which housing assistance (e.g., long-term leasing orrental assistance) and supportive services are provided to assist households with at least one member (adult orchild) with a disability in achieving housing stability.

Responsibilities

• Interacts with patients via phone calls, medical, or social services appointments, in their home in collaboration withanother team member, community spaces on PSH properties, and other locations per program guidelines, tobridge the gap between systems.
• Serves as a point of contact for patients enrolling in PSH HCC.
• Collaborates with PSH HCC partners, including Integral Care, Central Health, ECHO, and PSH site case managerson patient-centered care.
• Coordinates and oversees implementation of program goals, processes, schedules, and standards in collaborationwith program managers.
• Supervises Care Management team members, including hiring, onboarding, competency/quality monitoring,evaluations, and performance management.
• Serves as a liaison to program managers to support data engagement, population health initiatives, and valuebasedcare principles.
• Trains staff, assigns and monitors completion of tasks, and ensures all team members understand goals andexpectations.
• Assesses learning needs, develops competency plans, and provides learning opportunities for direct reports.
• Manages scheduling for Care Management staff; oversees timekeeping, time‑off requests, and staffing levels.
• Oversees daily staff activities and provides support for day‑to‑day questions.
• Leads team huddles.
• Manages escalated patient issues using a Trauma‑Informed Care approach and provides direction and follow‑up tostaff and care teams.
• Compiles data for departmental and program reporting.
• Reviews staff work for accuracy, evaluates performance, and provides coaching as needed.
• Implements corrective actions, including coaching, disciplinary steps, demotion, or termination when necessary.
• Participates in quality initiatives to ensure compliance with evidence‑based guidelines and improve patientoutcomes.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients andfamilies, as well as appropriate use of resources.
• Empowers patients and/or their families to be engaged and active participants in their care management.
• Performs thorough biopsychosocial assessments with patients and their families to identify care needs, strengths,and potential barriers to optimal health outcomes.
• Develops a comprehensive care plan in collaboration with patients, families, and the primary care team.
• Continuously monitors patients’ biopsychosocial needs and provides timely follow-up in alignment with programprotocols to ensure continuity of care and support.
• Coordinates transitions between sites and providers of care.
• Provides education and guidance to patients and their families to support understanding of health conditions,promote self-management, and enhance overall well-being.
• Coordinates and streamlines patient referrals to appropriate community-based services, ensuring timely access toresources that support health, wellness, and social needs.
• Delivers direct nursing care in alignment with program protocols, including executing standing delegation ordersand administering medications and treatments in accordance with established standards of practice.
• Performs patient triage by assessing clinical and psychosocial needs to prioritize care and ensure timelyintervention and appropriate resource allocation.
• Accurately completes all documentation related to direct and indirect patient care in a timely manner, ensuringthat medical records are up-to-date, thorough, and compliant with organizational standards.
• Plays an active role in daily unit-based patient care huddles and periodic clinic-wide informational meetings,patient conferences, and planni