RN Case Manager (Remote)

Vytalize Health is a leading value-based care platform. It helps independent physicians and practices stay ahead in a rapidly changing healthcare system by strengthening relationships with their patients through data-driven, holistic, and personalized care. Vytalize provides an all-in-one solution, including value-based incentives, smart technology, and a virtual clinic that enables independent practices to succeed in value-based care arrangements. Vytalize's care delivery model transforms the healthcare experience for more than 250,000+ Medicare beneficiaries across 36 states by helping them manage their chronic conditions in collaboration with their doctors.

The RN Case Manager works with the clinical department and acts as a liaison with our physician practices. The RN Case Manager advocates for personalized treatment options that address a patient’s unique care needs. The RN Case Manager has a patient-forward approach that is centered in the value-based care model, offers education and guidance for navigating complex medical decisions, and creates and manages the plan of care for patients with chronic or serious conditions.

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 the patient/caregiver has 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 PCPs, NPs, 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 teams, family/caregivers, payers, and community resources. Implement interventions that improve health outcomes, lower costs, and enhance the patient experience. Work collaboratively with provider offices, SNFs, hospitals, and other Clinical Services teams to support each patient’s needs efficiently and effectively. Assist in coordination across the continuum of care while maintaining confidentiality. Guide patients through the healthcare 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. Provide community resources to patients as needed and 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. Depending on market location, minimal travel may be required to visit provider offices to help enhance provider office engagement (less than 5%).