Provide patient-centered care remotely as an RN Case Manager, delivering clinical support through telehealth to individuals managing chronic conditions and preventive health needs. You'll conduct thorough phone assessments, gather medical and social insights, and create tailored care plans that align with each patient’s goals and circumstances.
Clinical Responsibilities
- Perform comprehensive telephonic evaluations and update patient records, including medications, diagnoses, and preventive care status.
- Deliver evidence-based education on disease management and wellness, helping patients understand treatment options and stay engaged in their care.
- Monitor patient progress through regular follow-ups, adjusting care strategies as needed and ensuring continuity with providers.
- Complete Medicare Annual Wellness Visits remotely under physician oversight, supporting compliance with regulatory standards.
- Document all interactions accurately in the EHR and care coordination systems in real time.
Collaboration and Coordination
You’ll work closely with non-clinical support staff—called Healthguides—to connect patients with resources for transportation, food security, and other social determinants of health. This team-based model ensures holistic support beyond medical needs.
Engage in AI-assisted outreach initiatives designed to identify and support high-risk individuals. Use phone, text, email, and patient portals to maintain contact and improve care adherence.
Work Environment and Requirements
This role is primarily remote, requiring a quiet, private workspace at home. You must be licensed as a Registered Nurse in good standing and comfortable using EHRs, telehealth platforms, and digital communication tools. Occasional local travel (10–15%) may be needed for site visits or training.
Stay current through regular virtual team meetings and clinical education. Your work directly supports quality benchmarks such as HEDIS and NCQA by promoting preventive screenings and effective chronic disease management.
The ideal candidate has experience in case management, telehealth, or remote nursing and is familiar with Medicare AWVs, quality reporting, or AI-enhanced care models. A commitment to health equity and patient advocacy is essential.
