Transitions of Care RN Case Manager

Accountabilities:

• • Engage recently discharged, high-risk patients by phone to understand their needs, priorities, barriers, and available support, using technology and data tools to guide care.
  • Conduct comprehensive assessments covering comorbidities, prior emergency department visits and hospitalizations, medications, psychosocial factors, and patient preferences.
  • Develop individualized care plans with patients and caregivers, defining problems, goals, and interventions while monitoring progress and adjusting plans as needed.
  • Educate patients and caregivers about chronic conditions, warning signs, medication adherence, exacerbation planning, and other strategies that support safer recovery.
  • Identify clinical and social risk factors, respond to warning signs, and proactively close gaps in care.
  • Coordinate closely with nurse practitioners and physicians to facilitate smooth handoffs, appropriate follow-up, and continuity throughout the post-discharge period.
  • Connect patients with appropriate clinical services, community-based organizations, social support, durable medical equipment, and other resources.
  • Collaborate with primary care partners and interdisciplinary teams to deliver evidence-based, accessible, and effective care.
  • Serve as a patient advocate, helping individuals and caregivers understand complex medical information and confidently navigate the healthcare system.

  Requirements

  • Hold an unrestricted U.S. Compact Registered Nurse (RN) license and be able to obtain additional state licenses as required.
  • Bring 3–4 years of RN care management or telephonic case management experience.
  • Be available Monday through Friday, 8:30 a.m. to 5:00 p.m. MST/PST, with preference for candidates located in CT, MT, or PT time zones.
  • Demonstrate strong clinical assessment, analytical thinking, problem-solving, and care-planning abilities.
  • Communicate complex medical information clearly and compassionately using plain language.
  • Be comfortable spending significant time on the phone building trust with patients and caregivers, educating them, and coordinating their care.
  • Work effectively in an environment guided by productivity, performance, quality, and patient-experience metrics.
  • Demonstrate adaptability, empathy, sound judgment, organization, and a strong commitment to patient advocacy.
  • Health insurance experience, particularly Medicare Advantage, is preferred.
  • Experience with Special Needs Plans, population health, transitions of care, or related case/care management is a plus.

  Benefits

  • Annual salary range of $85,000–$100,000, with actual compensation based on qualifications, experience, education, certifications, licensure, skills, and work location.
  • Employer-sponsored medical, dental, and vision coverage with low or no employee premiums.
  • Generous paid time off.
  • $100 monthly mobile or internet stipend.
  • Stock options for all employees.
  • Bonus eligibility for eligible roles.
  • Parental leave program.
  • 401(k) retirement savings program.
  • Additional benefits included in the comprehensive total rewards package.
  • Fully remote work environment.