Title:  Nurse Care Manager-Annual Wellness Visit

Division:  Ambulatory Operations
Schedule:  Monday-Friday; 8:00 a.m. -5:00 p.m.
Work Location:  Texas Medical Center, Houston, TX
Salary Range:  Commensurate with Experience
FLSA Status:  Exempt
Requisition ID:  5331


The Clinical Nurse Care Manager is responsible and accountable for coordinating the care of a specified group of patients. Assesses, plans, implements, coordinates, monitors, and evaluates options to facilitate the continuum of care. Educates staff regarding effective allocation of resources while encouraging provision of high quality patient care.

Job Purpose

Position sees Medicare Annual Wellness Visit patients to help close Quality measure gaps to generate Medicare Shared Savings. The position assists with seeing these patients for the physicians to allow physicians to see patients with more complex issues.

Job Duties
  • Providing patient care servicing Medicare patients for Annual Wellness Visits at various locations throughout the Medical Center.
  • Assists with closing care gaps to improve quality metric scores.
  • Ensures the appropriate amount of visits are scheduled each day in accordance with the program. 
  • Performs all patient screenings in accordance with CMS guidelines for annual wellness visits.
  • Perform initial assessment of patients. Assess patient needs for healthcare resources based on medical condition, patient resources, and potential barriers to optimal progression through the healthcare system. 
  • Functions as a resource to clinical staff regarding patient assessment and plan of care or performs patient assessment and develops a plan of care to assure consistent and appropriate care is provided in a patient focused manner. 
  • Manages each patient's transition through the system and transfers accountability to the appropriate person upon entry into another clinical service. Serves as a patient advocate to assure patient education is completed. 
  • Plans and implements (through multi-disciplinary meetings, messaging and conversations with the care team, and with patient or family) strategies to reduce resource consumption, and achieve high quality positive patient outcomes.
  • Evaluate and measure outcomes in order to continuously improve practice and to enhance outcomes. 
  • Identifies changes in patients’ clinical progression or needs to assure continuity of care. The following may be assessed to determine needs: medical, rehabilitative, psychosocial and physical needs. Assures timely referral to other services to facilitate ongoing care needs of patient. 
  • Serve as a patient advocate. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions. 
  • Coordinates the provision of social and other support services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services. 
  • Utilizes appropriate resources in cases that present ethical dilemmas. 
  • Communicate with payers to facilitate the patient’s effective and efficient movement through the healthcare system. 
  • Able to complete all aspects of the Nurse, Registered II (BA 12) Job Description as required to support patient care for the assigned population. 
  • Understands and adheres to the college Medical Center compliance standards as they appear in the Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy. 
  • Keeps abreast of all pertinent federal, state, and the college regulations, laws, and policies as they presently exist and as they change or are modified. 
  • Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs. 
Minimum Qualifications
  • Bachelor's degree in Nursing.
  • Four years of relevant experience.
  • Current license as a Registered Nurse (RN) by the State of Texas Board of Nursing. 
Preferred Qualifications
  • Eligibility or Certification in Case Management by the Texas Department of State Health Services (DSHS).





Baylor College of Medicine is an Equal Opportunity/Affirmative Action/Equal Access Employer.