Transitions of Care RN Case Manager

This position 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.

Responsibilities

• 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.
• Cook up 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.