Transitions of Care RN Case Manager

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Transitions of Care RN Case Manager based in United States.

This remote role supports high-risk patients during the critical 30 days following hospital discharge.
You will provide short-term, telephonic, interdisciplinary care management focused on preventing avoidable readmissions.
The role combines clinical assessment, patient education, care coordination, and advocacy.
You will build individualized care plans that address medical, psychosocial, medication, and resource-related needs.
Working closely with nurses, physicians, social workers, primary care providers, and community resources, you will help patients navigate complex care journeys.
The environment is collaborative, technology-enabled, and focused on measurable outcomes and exceptional patient experiences.
This is an opportunity to make a direct difference for vulnerable patients while helping shape innovative approaches to healthcare delivery.

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.

How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.