Transitions of Care RN Case Manager

TL;DR

Transitions of Care RN Case Manager: Telephonic short-term interdisciplinary care management for high-risk patients during the 30 days post-discharge, with an accent on assessments, care plan development, and closing care gaps through coordinated follow-up. Focus on explaining complex medical information in plain language, educating patients on chronic conditions and “red flags,” and partnering with providers and community resources to improve health outcomes.

Location: Remote (USA). Working hours: Monday–Friday 8:30–5:00 MST/PST. Candidates must be located in CT/MT/PT time zones.

Salary: $85,000–$100,000 / year

Company

hirify.global helps older Americans navigate healthcare and improve outcomes through integrated care and technology.

What you will do

• Engage newly discharged patients telephonically to understand needs and conduct post-discharge assessments.
• Develop and continuously evaluate individualized care plans with patients and caregivers, including goals, interventions, and progress tracking.
• Educate patients on chronic conditions, teach “red flags,” and support plans during exacerbations and barriers to care (e.g., medication adherence).
• Provide active care management to close gaps identified through patient-reported “red flags.”
• Coordinate care with TOC Nurse Practitioners and Physicians, PCP partners, and Devoted Community Guides (social workers).
• Coordinate post-treatment care and DME needs and refer patients to Devoted Medical when applicable.

Requirements

• Unrestricted Compact RN license in the United States with ability to secure other licensure states.
• 3–4 years of experience in RN care management and/or telephonic case management.
• Location/time zone requirement: located in CT/MT/PT time zones and able to work Monday–Friday 8:30–5:00 MST/PST.

Nice to have

• Experience with Special Needs Plans, Population Health, or Transitions of Care case/care management.
• Health insurance experience, especially Medicare Advantage.
• Comfort working with performance/productivity metrics focused on quality outcomes and patient experience.
• Clinical analytical thinking to tailor care to individual patient needs.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off and parental leave program.
• $100 monthly mobile/internet stipend.
• Stock options for all employees and bonus eligibility (excluding Director and above).
• 401K program.
• Total rewards apply to full-time employees only (intern and contract positions not eligible).

Hiring process

• Interview process begins with a talent partner providing additional compensation details and total rewards information.