You will employ a variety of strategies, and techniques to manage a member's physical, environmental, and psycho-social health issues. You will resolve barriers that hinder care. You will ensure the patient is progressing towards desired outcomes by managing patient care through assessments and evaluations and may create member care plans. You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas. You will make decisions regarding own work methods that require minimal direction and receive guidance where needed.

Responsibilities:

• Conduct Transitions of Care Management for a subset of the patient population, including hospital, observation, and post-acute care follow-up.
• Complete post-discharge outreach and assessment, including review of discharge needs, medication understanding, PCP follow-up status, symptoms, barriers, and support needs.
• Support coordination of PCP follow-up appointments and oversee discharge instructions and PCP-established next steps.
• Provide assessment guidance and supportive consultation to other team members, handling escalated complex cases within RN scope of practice.
• Develop a holistic view of patient needs related to Social Determinants of Health.
• Identify existing barriers to engagement with necessary resources and supports.
• Provide education around maintenance of chronic health conditions, medication understanding, symptom monitoring, available behavioral care options, and social support resources.
• Be a liaison between the patient, caregiver, direct care providers, practice contacts, and interdisciplinary team members to support navigation of internal and external systems.
• Support patients' self-determination and motivate patients to meet the health goals they have identified.
• Refer patients to necessary services and supports across the interdisciplinary team and community resource network.
• Participate in interdisciplinary care team or provider/practice touchpoints when indicated to support transition-of-care coordination.
• Support the patient's family and caregiver support systems and participate in patient/family discussions when needed and appropriate in a virtual setting.
• Maintain patient confidentiality following HIPAA.
• Document patient encounters and outreach activity in the designated medical record or documentation system promptly.
• Follow general policies related to fire safety, infection control, attendance, and remote work expectations.

Required Qualifications:

• Registered Nurse (RN license).
• 4+ years of experience working in human services, care coordination, care management, case management, or transitions of care.
• Work in a fully remote/work-at-home environment using electronic documentation and approved systems. Remote work requires a private, secure workspace appropriate for confidential patient communication and HIPAA-compliant documentation.
• Advanced clinical experience.
• Flexibility to transition and adjust in an evolving role.
• Compassion and desire to advocate for patient needs.
• Ability for confidentiality and protect PHI in a remote work setting.
• Can work in the Eastern Time Zone.

Preferred Qualifications:

• Experience working in care/case management, transitions of care, or post-discharge patient support.
• Prior value-based care experience and experience working with complex senior populations.
• Experience working within interdisciplinary teams and with PCP practice partners.
• Experience providing patient education related to chronic condition management, medications, discharge instructions, and follow-up coordination.
• Bilingual in English and Spanish or Creole with the ability to speak, read, and write in both languages without limitations or assistance.
• Prefer residence in the Treasure Coast, FL area.

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Scheduled Weekly Hours

Pay Range

Description of Benefits