Transitions of Care RN Case Manager

Role Overview

• Engaging 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.
• 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.

Requirements

• 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

Benefits

• 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....