Transitions of Care RN Case Manager

Devoted Health•Waltham, MA

9d•$85,000 - $100,000

About The Position

The Transitions of Care RN Case Manager provides telephonic, short-term, interdisciplinary care management to high-risk patients during the 30 days after discharge, with the goal of helping them navigate the healthcare system safely and reducing readmissions. The role advocates for patients by coordinating care and ensuring they have the resources and support needed to achieve better health outcomes. The RN engages newly discharged patients by phone, assesses their clinical and psychosocial needs, and develops and evaluates care plans with patients and caregivers. The role includes educating patients about chronic conditions and warning signs, addressing barriers such as medication adherence, and coordinating post-discharge care with clinicians, community resources, and primary care partners. The ideal candidate is compassionate, solution-oriented, adaptable, and committed to patient experience and quality outcomes. The stated schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. MST/PST. Candidates should be located in CT, MT, or PT time zones. The listed salary range is $85,000–$100,000 per year. The position's total rewards package includes employer-sponsored health, dental, and vision plans with low or no premiums; generous paid time off; a monthly mobile or internet stipend; stock options; bonus eligibility; parental leave; and a 401(k) program. The total rewards package is for full-time employees only.

Requirements

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 or telephonic case management experience.
Work Monday through Friday, 8:30 a.m. to 5:00 p.m. MST/PST.
Be located in a CT, MT, or PT time zone.

Nice To Haves

Enthusiasm for spending meaningful time on the phone with patients or caregivers to build trust, educate, and coordinate care.
Comfort and confidence working in a performance- and productivity-metrics-guided environment focused on quality outcomes and patient experience.
Health insurance experience, particularly Medicare Advantage.
Prior Special Needs Plan, Population Health, or Transitions of Care case or care management experience.
Clinical analytical thinking to apply skills to individual patient needs.
Telephonic care or case management experience.

Responsibilities

Engage newly discharged patients by phone to understand their needs, using technology and data tools.
Assess comorbid conditions, emergency department and hospitalization history, medications, psychosocial factors, and patient values and preferences.
Develop care plans with patients and caregivers, including problems, goals, and interventions, and continuously evaluate progress.
Explain complicated medical terms in plain language.
Educate patients about chronic conditions, warning signs, plans for exacerbations, and barriers to care such as medication adherence.
Respond to warning signs and provide active care management to close care gaps.
Partner with Transitions of Care Nurse Practitioners and Physicians to support handoffs, follow-up, and coordinated post-discharge care.
Refer patients to Devoted Medical when applicable and coordinate with that team on patient care.
Work with Devoted Community Guides to identify community organizations that can help patients meet their goals.
Coordinate post-treatment care and durable medical equipment needs.
Collaborate with primary care provider partners to coordinate evidence-based, effective, and accessible care.

Benefits

Employer-sponsored health, dental, and vision plans with low or no premiums.
Generous paid time off.
$100 monthly mobile or internet stipend.
Stock options for all employees.
Bonus eligibility for roles below Director level; Sales roles may be eligible for commission.
Parental leave program.
401(k) program.

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