VBC Operations
If you are a current Duly/SBC/QMG employee, please apply through the Internal Career Site.
The Remote TCM Nurse Care Manager collaborates with physicians, patients, caregivers, and interdisciplinary healthcare teams to support patients following hospital discharge. This role is responsible for engaging patients during the 30-day post-discharge period, completing clinical assessments, coordinating care transitions, facilitating timely follow-up care, and implementing interventions designed to reduce avoidable readmissions and improve patient outcomes. The Nurse Care Manager provides telephonic and virtual care management services while promoting safe, effective transitions across the continuum of care.
Essential Duties & Responsibilities
• Review hospitalization and discharge reports to identify patients eligible for Transitional Care Management services.
• Conduct post-discharge outreach, assessments, and enrollment activities in accordance with program requirements.
• Manage an assigned caseload of patients during the 30-day post-discharge period.
• Develop, implement, and monitor individualized care plans with measurable goals and interventions.
• Coordinate follow-up appointments, medication reconciliation, and post-discharge services.
• Collaborate with providers, office staff, hospitals, skilled nursing facilities, home health agencies, and community resources to facilitate care transitions.
• Identify and address barriers to care, including social determinants of health.
• Educate patients and caregivers regarding discharge instructions, disease management, and symptom escalation.
• Maintain accurate and timely documentation within the EMR and care management platforms.
• Monitor patients for risk factors associated with avoidable readmissions and escalate concerns appropriately.
• Collaborate with care management, quality, and population health teams to support value-based care initiatives.
• Perform other duties as assigned.
Knowledge, Skills & Abilities
• Knowledge of transitional care management, care coordination, and readmission prevention principles.
• Strong communication, assessment, and critical thinking skills.
• Ability to work independently in a remote environment.
• Strong organizational and time-management abilities.
• Proficiency with EMR systems, care management platforms, and Microsoft Office.
• Knowledge of community resources and social determinants of health.
Education / Certification
• Current unrestricted Registered Nurse (RN) license required.
• Associate Degree in Nursing (ADN) required, Bachelor of Science in Nursing preferred.
• CCM, ACM, or equivalent certification preferred.
Experience
• Minimum two years of clinical nursing experience required.
• Two years of case management, care coordination, transitional care management, or population health experience preferred.
• Remote or telephonic care management experience preferred.
If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.
The compensation for this role includes a base pay range of $ 67K-101K with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package
Artificial Intelligence Disclosure
Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.
