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%).
Must be located in the Kansas City, MO region preferably, or reside in Kansas.
Bachelor’s degree in Nursing preferred, or Associate’s degree in Nursing with relevant experience.
5 years’ experience as an RN or RN Case Manager providing complex care management.
Minimum of 3 years’ experience in Med Surg or Home Health.
Experience providing Transitions of Care.
Startup experience preferred.
Unencumbered RN license, compact nursing license, or compact nursing license obtained within 6 months of hire.
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, with a sense of ownership and comfort operating in ambiguity.
Solution-oriented with the ability to think strategically and creatively in decision-making.
Able to work independently and engage as part of a fully remote team.
Coachable and able to take direction and feedback well, while also being forward-thinking to challenge the status quo.
Comfortable providing care management using telehealth capabilities.
Proficient with Microsoft Office Suite or related software.
Ability to effectively and efficiently use various documentation tools and technological platforms, including EMRs; comfortable with digital technologies.
Demonstrates a positive attitude and respectful, professional customer service.
