Transitions of Care RN Case Manager

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

📋 Description

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

• Act as an advocate for patients by coordinating care and ensuring access to essential resources and support.

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

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

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

• Translate complex medical terminology into layman's terms for better understanding.

• Educate patients about chronic conditions, red flags, plans for exacerbation, and challenges related to medication adherence.

• Provide proactive care management to bridge care gaps.

• Collaborate with TOC Nurse Practitioners and Physicians to ensure seamless transitions, follow-ups, and coordinated care post-discharge.

• Refer patients to Devoted Medical when appropriate.

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

• Oversee post-treatment care and durable medical equipment (DME) requirements.

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

⛳️ Requirements

• An unrestricted Compact RN license obtained in 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.

• Reside in CT/MT/PT time zones.

• A passion for engaging with patients and caregivers over the phone to establish trust, provide education, and coordinate care.

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

• Experience in health insurance, especially Medicare Advantage.

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

• Clinical analytical thinking that enables you to tailor your skills to meet the unique needs of each patient.

• Experience in telephonic care/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 Director and above.

• Parental leave program.

• 401K program.