Transitions of Care RN Case Manager

Job DescriptionA bit about this role: We want to help patients navigate the healthcare system in a better and safer way, and case management is critical to achieving this for our most vulnerable and complex patients. You'll be responsible for providing telephonic, short-term, interdisciplinary care management in the 30 days post-discharge for patients at high risk for readmission. You'll serve as an advocate for these patients, coordinating care and ensuring they have the necessary resources and support to achieve better health outcomes. Our ideal RN is caring, compassionate, solution-oriented and enthusiastic about providing an outstanding experience for Devoted Health’s patients. They are committed to integrity, excellence, and empowering our patients to confidently navigate the healthcare system and live healthier lives. They are ready to innovate, adaptable to a continuously evolving startup environment, working with the whole Devoted family to create a revolution in how care is delivered.Your Responsibilities and Impact will include:Working with patientsEngaging with our newly discharged patients telephonically to understand their needs, supported by technology and data tools.Conducting assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences.Developing care plans in partnership with patients and their caregivers - problems, goals, interventions - while continuously evaluating the patient’s progress.Explaining complicated medical terms in plain language.Educating patients on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence.Hearing the red flags and providing active care management to close the gaps. Working with other providers and resourcesPartnering with the TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow-up, and coordinated care during the post-discharge period.Referring patients to Devoted Medical when applicable and working closely on partnering for patient care.Working closely with Devoted Community Guides (locally-based social workers) to identify community-based organizations to support our patients in meeting their goals.Coordinating post-treatment care and DME needs.Collaborating closely with our PCP partners, to coordinate care and deliver evidence based, effective, and accessible health care.Required skills and experience: An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states3-4 Years of Experience of RN Care Management/telephonic case management experience Working hours are Monday-Friday 8:30-5:00 MST/PST. We are looking for candidates who are located in CT/MT/PT time zones.Desired skills and experience: Enthusiasm for working in a setting where meaningful time is spent on the phone with patients and/or their caregivers to build trust, educate, and coordinate careComfort and confidence working in an environment guided by performance and productivity metrics, with a focus on quality outcomes and patient experienceHealth insurance experience, particularly Medicare AdvantagePrior Special Needs Plan, Population Health, or Transitions of Care case/care management experienceClinical analytical thinking that allows you to apply your skills to the individual needs of each patientTelephonic care/case management experienceSalary Range: $85,000 - $100,000 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.Our Total Rewards package includes:Employer sponsored health, dental and vision plan with low or no premiumGenerous paid time off$100 monthly mobile or internet stipendStock options for all employeesBonus eligibility for all roles excluding Director and above; Commission eligibility for Sales rolesParental leave program401K programAnd more....*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every per