As a Remote RN Case Manager at Guidehealth, you will build trusted relationships with patients over the phone, helping them navigate complex health needs, understand care plans, and improve well-being. This role offers meaningful patient connection without the physical demands of bedside care, with most work conducted remotely and occasional local travel.
What You'll Do
- Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs.
- Reviewing and updating medical histories—including medications, chronic conditions, and preventive care.
- Developing individualized care plans and guiding patients through their treatment goals and care options.
- Providing empathetic, evidence-based education on chronic disease management and preventive health.
- Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers.
- Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision.
- Partnering with Healthguides who support non-clinical needs like scheduling, transportation, food assistance, and SDOH resources.
- Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement.
- Advocating for patients, helping them access the right resources at the right time.
- Documenting clearly and accurately in the EHR and care-management systems during and after calls.
- Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions.
- Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards.
- Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients.
- Collaborating in AI-driven outreach programs that help connect with vulnerable populations.
- Protecting patient privacy in a secure, private home workspace.
- Performing additional responsibilities as needed to support patients and the care team.
What We're Looking For
- Registered Nurse (RN) license in good standing
- Clinical experience in care management, case management, or a related field
- Experience conducting patient assessments and developing care plans
- Strong understanding of chronic disease management and preventive health
- Proficiency in using EHR and care-management systems
- Ability to work independently in a remote environment with a secure and private workspace
- Excellent communication and empathetic listening skills
- Experience with telehealth or remote patient care
- Ability to travel locally 10–15% of the time to clinical sites
Nice to Have
- Experience with Medicare Annual Wellness Visits (AWVs)
- Familiarity with HEDIS and NCQA quality measures
- Experience working with social determinants of health (SDOH) resources
- Background in population health, care coordination, or value-based care
- Experience using AI-supported tools in patient outreach or care management
Technical Stack
- EHR systems
- Care-management systems
- Telehealth platforms
- Patient portals
- AI-supported outreach tools
- Phone, text, and email communication platforms
Team & Environment
- Interdisciplinary care team including Healthguides and clinical supervisors
Benefits & Compensation
- Remote work with flexible scheduling
- Opportunity to make a direct impact on patient well-being
- Collaboration with supportive Healthguides for non-clinical patient needs
- Access to ongoing clinical training and education
- Participation in innovative AI-driven patient outreach programs
- Secure and private home workspace required (support may be provided)
Work Mode
- Primarily remote with 10–15% local travel to clinical sites in the hiring area
Guidehealth is an equal opportunity employer committed to a diverse and inclusive workplace.
