Engaging with our newly discharged patients telephonically to understand their needs
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
Partnering 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

An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states
3-4 Years of Experience of RN Care Management/telephonic case management experience
Fully bilingual in English/Spanish

Employer sponsored health, dental and vision plan with low or no premium
Generous paid time off
$100 monthly mobile or internet stipend
Stock options for all employees
Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
Parental leave program
401K program
And more....

Bilingual RN Case Manager – Transitions of Care

Key skills