RN Case Manager - Remote

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. As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.

As an RN Case Manager, you will partner with clinical teams to provide complex case management and strengthen the connection between the patient, the primary care physician/medical practice staff, and the patient’s care team. The Registered Nurse (RN) Case Manager is responsible for a specific patient population experiencing complex medical conditions, socio-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 collaborates with their assigned Healthguides to achieve optimal quality, clinical, and financial outcomes. This is primarily a remote position that will require travel as needed (10%-15%) to clinical sites in the Atlanta, GA area.

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 such as 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.