Transitions of Care RN Case Manager

Job Description 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 Working with patients 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. Hearing the red flags and providing active care management to close the gaps. Working with other providers and resources 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. Required skills and experience 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 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 care Comfort and confidence working in an environment guided by performance and productivity metrics, with a focus on quality outcomes and patient experience Health insurance experience, particularly Medicare Advantage Prior Special Needs Plan, Population Health, or Transitions of Care case/care management experience Clinical analytical thinking that allows you to apply your skills to the individual needs of each patient Telephonic care/case management experience Salary and Compensation Salary Range: $85,000 - $100,000 / year Benefits Our Total Rewards package includes: 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.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Company Culture and Values Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well‑being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world‑class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we’re going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment. #J-18808-Ljbffr Devoted