Registered Nurse, Case Manager - High Risk Population (Housing Support Program)

Overview

The RN Case Manager for High Risk Populations will serve as the lead for each multidisciplinary CaseManagement(CM) team in assessment of medical and social needs for the patient. The RN Case Manager will appropriately assign and delegate non-medical CM tasks to the social worker , case manager or Community Health Worker for timely follow up and navigation. The RN Case Manager will work in conjunction with Social Workers, Case Managers, Community Health Workers, Physicians, Advanced Practice Providers, community partners and other care team members to provide case management and navigation services, while working in collaboration with inpatient care teams , ambulatory teams, transitions of care teams and other Central Health teams to support patients in the High Risk Population program. The RN Case Manager is an integral member of the High Risk Population team and supports with oversight and growth of programs and servicesWe invite you to join a compassionate team that is committed to serving individuals with the greatest needs. The RN practices professional nursing as defined by the Texas Board of Nursing, Texas Nurse Practice Act and by adhering to organizational policies, procedures, and guidelines. Our nurses are committed to providing a collaborative environment to provide the safest and highest quality of care for our patients.

 

This is an onsite position. Only candidates that live or will live in the Austin area will be considered for this role.

Responsibilities

Essential Functions:

• Conduct patient assessments, including home visits, clinic accompaniments, and visits to our local shelters and homeless navigation centers to evaluate medical, behavioral health, functional needs, and social determinants of health using trauma informed approaches.
• Provide rapid clinical assessment and intervention during crises such as homelessness, substance use episodes, or psychiatric destabilization; deescalate situations and coordinate emergency or urgent services to ensure patient safety.
• Develop and manage culturally responsive, evidence-based care plans with measurable goals tailored to complex patient needs, ensuring alignment with patient preferences and clinical best practices.
• Facilitate seamless care across primary care, specialty, dental, behavioral health, and community systems.
• Complete hospital referral reviews, discharge planning, medication reconciliation, and timely appointment coordination.
• Coordination with PCP for medication management for PCP prescribed therapies, ensuring review, adherence support, pharmacy coordination, and individualized medication education.
• Establish patient centered medication routines and accommodate learning barriers.
• Educates and empowers patients to navigate the healthcare system effectively, promoting the use of appropriate levels of care and timely access to primary and outpatient services to reduce avoidable emergency department utilization. Integrates preventive and chronic disease management strategies by addressing remediable barriers to medical independence, facilitating access to preventive screenings and routine care, and building patient skills forsafe and effective self management (e.g., medication organization, monitoring health indicators, safe treatment practices, and use of overdose prevention tools).
• Address social needs by navigating housing, food, transportation, financial assistance, and behavioral health resources. Advocate for patients across Medicaid, disability, legal aid, and other complex systems to reduce barriers to care.
• Provide tailored education that accommodates disabilities and literacy levels. Utilize therapeutic communication and shared decision making to strengthen engagement, improve health literacy, and support long term self management
• Serve as the clinical lead for the case management team, supporting community health workers and collaborating with physicians, advanced practice providers, specialists, and social workers to coordinate comprehensive care and reduce disparities
• Apply expertise in high risk populations to identify emerging needs, manage complex cases, close care gaps, and support equitable health outcomes through preventive care, chronic disease management, and stratified outreach.
• Provide direct nursing care and clinical support including vital signs, medication and disease education, basic wound care, in basket management, MyChart responses, pre certifications, referrals, authorizations, and scheduling for clinics, hospitals, and ancillary services.
• Support patient safety, experience, and problem resolution by addressing and resolving patient/program concerns, maintaining positive partner relationships, applying supportive conflict resolution practices, and escalating emergencies or clinical concer