Bilingual (English/Spanish) Transitions of Care RN Case Manager

A 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. Responsibilities and Impact Engage newly discharged patients telephonically to understand their needs, supported by technology and data tools. Conduct assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences. Develop care plans in partnership with patients and their caregivers—problems, goals, interventions—while continuously evaluating each patient’s progress. Explain complicated medical terms in plain language. Educate patients on chronic conditions, including teaching red flags, developing plans during exacerbation, and identifying barriers to important care elements such as medication adherence. Respond to red flags and provide active care management to close care gaps. Working with Other Providers and Resources Partner with TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow‑up, and coordinated care during the post‑discharge period. Refer patients to Devoted Medical when applicable and work closely on partnering for patient care. Collaborate with Devoted Community Guides (locally‑based social workers) to identify community‑based organizations that support patients in meeting their goals. Coordinate post‑treatment care and DME needs. Work closely with PCP partners to coordinate care and deliver evidence‑based, effective, and accessible health care. Required Skills and Experience Unrestricted Compact RN license obtained in the United States with the ability to secure licensure in other states. 3‑4 years of RN Care Management / telephonic case management experience. Fully bilingual in English/Spanish. Working hours Monday‑Friday 10:00‑18:30ET or 10:30‑19:00ET; located in CT/MT/PT time zones. Desired Skills and Experience Enthusiastic about building trust, educating, and coordinating care via phone with patients and caregivers. Comfortable with a performance‑driven environment focusing on quality outcomes and patient experience. Experience in health insurance, particularly Medicare Advantage, Prior Special Needs Plan, Population Health, or Transitions of Care case/care management. Clinical analytical thinking to apply individualized care strategies. Telephonic care/case management experience. Salary Range $85,000 - $100,000 per year. Benefits Employer‑sponsored health, dental, and vision plans. 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, 401(k) program, and additional benefits. Equal Opportunity Employment Devoted Health is an equal opportunity employer. We comply with federal, state, and local laws and regulations to ensure a supportive work environment for all employees. We value diversity, collaboration, and the unique skills and perspectives each individual brings to our organization. #J-18808-Ljbffr