Remote RN Case Manager

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.  Join us as we put healthcare on a better path!!

As an RN Case Manager you will be partnering with clinical teams to provide complex case management and strengthen the connection between the patient and the primary care physician/medical practice staff. The Registered Nurse (RN) Case Manager is responsible for assisting patients to achieve their highest-level wellness. You will be Case Managing a specific patient population which includes complex medical conditions, social-economic and/or mental health co-morbidities. The RN Case Manager will optimize the patient’s health status through assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services available to the patient. The RN Case Manager will collaborate with approximately 5 patient care navigators and other members of a patient’s care team to achieve optimal quality, clinical, and financial outcomes.

Comprehensively assessing the healthcare and psychosocial needs of patients Reviewing and amending patient navigator interviews with the patient. Developing, implementing, and maintaining individualized care plans in accordance with all internal protocols and accreditation standards. Providing evidence-based clinical interventions based upon the individualized care plan goals. Partnering with patient navigator to manage non-clinical elements of care plan, such as making appointments, arranging transportation or food services, or other SDOH/non-medical patient needs. Providing ongoing outreach to patients, continuously monitoring patient data and adjusting plan of care accordingly. Developing with the PCP, patient specific escalation plans in the event of an acute, but non-emergent, exacerbation of key chronic conditions. Providing education regarding conditions and treatment options. Serving as an advocate for the patient and assist with accessing and engaging with services/resources that require clinical licensing, training, or knowledge. Following up on service or resource referrals Maintaining up to date documentation in the electronic medical health record as defined by protocol. Utilizing evidence-based clinical protocols and guidelines along with defined quality metrics