In partnership with patients, their families (as defined by the patient), and multidisciplinary teams, the Registered Nurse, Care Manager – Pediatrics and Obstetrics delivers patient-centered care coordination for individuals requiring specialized services. The Care Manager collaborates closely with patients, parents/guardians, caregivers, healthcare providers, educational systems, and interdisciplinary teams to ensure comprehensive, integrated, and compassionate care.

Essential Functions:

• Interacts with patients via telehealth and in-person clinic appointments, community spaces, schools, and other locations per program guidelines.
• Serves as a point of contact for patients enrolling in services.
• Collaborates with patients, parents/guardians, caregivers, medical providers, school systems, and interdisciplinary health care teams on patient-centered care.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, 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 program protocols 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 to resources that support health, wellness, and social needs.
• Delivers direct nursing care in alignment with program protocols, including executing standing delegation orders and 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 timely intervention and appropriate resource allocation.
• Accurately completes all documentation related to direct and indirect patient care in a timely manner, ensuring that 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 planning sessions. These engagements support quality assurance initiatives, care coordination, and continuous improvement in patient services.
• Participates in ongoing professional development through seminars and educational sessions, ensuring compliance with all licensure and certification requirements while staying current with best practices in the field.
• Participates in the implementation and evaluation of quality improvement strategies to ensure compliance with evidence-based guidelines and standards, while identifying opportunities to enhance patient outcomes and care delivery.
• Ensures all tasks provided and associated with patient care, patient administrative processes, and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Policies and Procedures.
• Cultivates and sustains positive working relationships and strategic partnerships with colleagues across departments—including leaders, support staff, providers, and other personnel. Communicates effectively with all members of the care team to deliver patient-centered, coordinated care.
• Engages respectfully and collaboratively with patients and their families, utilizing a trauma-informed care approach to foster trust and build positive, supportive relationships.
• Performs any other duties as needed to drive the vision, fulfill the mission, and abide by the values of this organization.

Knowledge, Skills and Abilities:

• Proficient in performing assigned clinical tasks with the necessary medical knowledge and competencies.
• Strong problem-solving abilities to effectively support both patients and staff in dynamic care environments.
• Exceptional attention to detail and accuracy in documentation, patient care, and task execution.
• Excellent communication skills, both verbal and written, to ensure clear, compassionate, and effective interactions.
• Expertise in delivering high-quality nursing care, aligned with professional standards and ethical guidelines.
• Demonstrated ability to manage multiple nursing responsibilities simultaneously, maintaining efficiency and quality.
• Hands-on experience in direct patient care, including safe and effective use of medical devices and equipment.
• Competent with healthcare technologies and systems, such as electronic health records (EHRs), patient documentation platforms, and standard office software (e.g., spreadsheets, word processing).

Minimum Qualifications:

Education:

• Associates Degree (higher degree accepted) Graduation from an accredited school of nursing.
• Bachelor's Degree (higher degree accepted) in Science of Nursing- Preferred
  (BSN)

Work Experience:

• Two (2) years of clinical nursing experience.
• 1 year of care/case management experience -Preferred
• 1 year of pediatric and/or obstetrics experience -Preferred

Required Certifications/Licensure:

• Registered Nurse (RN) License to practice nursing in the state of Texas. -Upon Hire
• BLS Provider CPR Certification Current Basic Life Support (BLS) Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross.  Will be required to maintain a current BLS CPR certification during employment.- upon Hire
• CPW Certification Case Management for Children & Pregnant Women certification through Texas Health & Human Services - Within 30 Days
• Valid Texas Driver's License - Upon Hire