Bilingual RN Case Manager, Transitions of Care

This is a fully remote position, open to applicants in United States.

📋 Description

• Deliver telephonic, short-term, interdisciplinary care management within 30 days post-discharge for patients identified as high-risk for readmission.

• Serve as an advocate for patients by coordinating care and ensuring the availability of essential resources and support.

• Engage with newly discharged patients via phone to assess their needs utilizing technology and data tools.

• Perform assessments that encompass comorbid conditions, emergency department/hospitalization history, medications, psychosocial factors, and patient values and preferences.

• Create care plans in collaboration with patients and caregivers, outlining problems, goals, and interventions, while monitoring progress.

• Simplify complex medical terminology into understandable language.

• Educate patients about chronic conditions, identifying red flags, developing exacerbation plans, and addressing barriers like medication adherence.

• Actively manage care to bridge care gaps.

• Collaborate with TOC Nurse Practitioners and Physicians on transitions, follow-up procedures, and coordinated post-discharge care.

• Refer patients to Devoted Medical when appropriate.

• Work alongside Devoted Community Guides to pinpoint community-based organizations.

• Organize post-treatment care and durable medical equipment (DME) needs.

• Partner with primary care physician (PCP) associates to provide evidence-based, effective, and accessible healthcare.

⛳️ Requirements

• A valid, unrestricted Compact RN license from the United States, with the capability to obtain licensure in additional states.

• 3-4 years of experience in RN Care Management or telephonic case management.

• Fully bilingual in English and Spanish.

• Reside in the CT/MT/PT time zones.

• A passion for spending meaningful time on the phone with patients and/or their caregivers.

• Comfort and confidence in a performance-driven environment, focusing on productivity metrics, quality outcomes, and patient experience.

• Experience in health insurance, particularly within Medicare Advantage.

• Prior experience in Special Needs Plans, Population Health, or Transitions of Care case/care management.

• Strong clinical analytical skills that enable personalized care for each patient's needs.

• Experience in telephonic care or case management.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all positions except for Director and above.

• Parental leave program.

• 401K program.