Vytalize Health
The RN Case Manager works with the clinical department and acts as a liaison between our physician practices and their patients. The The RN Case Manager advocates for personalized treatment options that address a patient’s unique care needs. The RN Case Manager uses a patient-centric approach that supports the value-based care model, offers education and guidance for navigating complex medical decisions, and coordinates care for patients when they need support the most, including post discharge and when social needs are not met. The RN Case Manager will support special clinical programs and initiatives to support VBC and shared savings goals.
Bachelor's Degree in Nursing 5 years experience as an RN or RN Care Manager Post Acute Care experience strongly preferred Transitions of Care experience strongly preferred Startup experience preferred Unencumbered RN license, compact nursing license preferred Accredited Case Manager (ACM) preferred Comfortable and able to adapt to rapid changes Excellent verbal and written communication skills Excellent organizational skills and attention to detail Entrepreneurial spirit, a sense of ownership and comfortable operating in ambiguity Solution oriented with the ability to think strategically and creatively in decision-making Able to work independently Coachable and able to take direction and feedback well, yet being forward-thinking to challenge the status quo Proficient with Microsoft Office Suite or related software. Demonstrate a positive attitude and respectful, professional customer service Acknowledge patient’s rights on confidentiality issues and follow HIPAA guidelines and regulations Passionate about patient experience Confident managing change, goal-oriented and has a growth mindset Comfortable with digital technology (including tools like MS Office, Google, various EMRs, etc.) and able to troubleshoot technology issues Compassionate and good at listening to patient or staff concerns Organized, efficient, and adaptable: able to carry out a variety of administrative and clinical duties Ability to critically think, solve problems, and bring professionalism to all situations Able to contribute to quality improvement and process improvement initiatives Maintain a professional and HIPAA compliant workspace Excellent written and verbal communication skills Strong clinical and problem-solving skills Strong attention to detail Proficiency in Microsoft Office Suite
You will be responsible for using your assessment and communication skills to engage with patients in need of clinical support to determine and prioritize their needs. You will deliver patient-centered care, provide exceptional customer service, and work within your scope of practice to provide evidence-based education, assessment, and care navigation Identify patient/caregiver education needs through telephonic assessment/engagement and ensure that patient/caregiver have adequate information to participate in the successful transition back to their home setting from an inpatient or post-acute facility stay Conduct timely telephonic clinical outreach to identified patients Collaborate with PCP, NP, and other members of the healthcare team to coordinate care for patients and actively help keep them stable at home Serve as the point of contact and informational resource for patients, care team, family/caregiver(s), payers, and community resources. Implement interventions that improve health outcomes, lower costs, and improve the experience for the patient. Work collaboratively with provider offices, SNFs, hospitals, and other teams in Clinical Services to support each patient’s needs most efficiently and effectively. Assist in the coordination across the continuum of care while maintaining confidentiality. Guide patients through the health care system and help them overcome barriers. Coordinate treatment and services for patients Schedule medical appointments as needed Communicate about a patient’s health condition with the patient and their family Provides community resources to patients as needed and to support resolution of SDoH Maintain a comprehensive working knowledge of community resources. Assume accountability for the quality of care. Continually seek new knowledge and learning that supports clinical care coordination. Support non-RN team members in their contributions to care coordination by educating and providing clinical guidance as needed May be asked to support the Director in day-to-day supervision of team members as needed.
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