Care Manager, RN
Curana Health
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- The Care Manager, TCM delivers telephonic care management for Curana patients during transitions, such as discharge from long-term care (LTC) facilities or senior living communities to acute care hospitals.
- They coordinate with hospital case managers and community staff for effective discharge planning.
- Collaborate with providers and interdisciplinary teams.
- Work to ensure quality care and reduce preventable rehospitalizations.
- Contact patients within two (2) business days of hospital discharge to assess needs and initiate the transitional care process.
- Schedule and coordinate timely follow-up appointments with a Curana provider and specialist within the required timeframes.
- Perform telephonic outreach to assess medication reconciliation, medical, or social needs.
- Identify gaps in care and address barriers to follow-up or treatment adherence.
- Perform transitional care management health assessments.
- Serve as a health coach to educate the patients and/or caregivers on discharge instructions, medication regimens, and chronic disease management.
- Provide referrals to community-based services, palliative care, or behavioral health services as needed.
- Apply clinical judgment to incorporate strategies that reduce patient risk factors and barriers.
- Communicate patient health updates to the Curana providers and support staff.
- Coordinate with the Care Management pod to coordinate provider TCM visit.
Requirements
- Must hold an active unrestricted compact RN or LPN nursing license.
- Ability to obtain additional state licenses, as needed.
- 2+ years of experience in nursing is required.
- Care settings may include inpatient, outpatient, or skilled nursing facilities.
- Strong clinical knowledge and understanding of chronic and acute conditions.
- Familiarity with CPT codes 99495 and 99496 requirements.
- Ability to identify red flags during post-discharge recovery.
- Familiarity with discharge summaries, medication changes, and follow-up needs.
- Demonstrated strategic thinking, process improvement, innovative thinking and team management expertise.
- Ability to communicate with patients and caregivers in an effective and caring manner.
- Effective written and verbal communication skills.
- Proficient in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
Benefits
- 100% remote position requires a reliable high-speed internet connection.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
nursingtelephonic care managementtransitional care managementmedication reconciliationhealth assessmentschronic disease managementCPT codes 99495CPT codes 99496discharge planningpatient risk assessment
Soft skills
strategic thinkingprocess improvementinnovative thinkingteam managementeffective communicationcaring mannerpatient educationproblem-solvingcollaborationinterpersonal skills
Certifications
active unrestricted compact RN licenseLPN nursing license