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Role Overview:
- Engage recently discharged, high-risk patients by phone to understand their needs, priorities, barriers, and support.
- Conduct comprehensive assessments covering comorbidities, medications, psychosocial factors, and patient preferences.
- Develop and monitor individualized care plans with patients and caregivers, adjusting as needed.
Key Responsibilities:
- Educate patients and caregivers on chronic conditions, warning signs, medication adherence, and exacerbation planning.
- Identify clinical and social risk factors, respond to warning signs, and proactively close gaps in care.
- Coordinate with nurse practitioners, physicians, and primary care partners for smooth handoffs and follow-up.
Requirements:
- Hold an unrestricted U.S. Compact RN license and be available Monday–Friday, 8:30 a.m. to 5:00 p.m. MST/PST.
- Bring 3–4 years of RN care management or telephonic case management experience.
- Demonstrate strong clinical assessment, analytical thinking, and compassionate communication skills.
Jobgether
Our partner is a healthcare organization that provides transitions of care support for high-risk patients post-hospital discharge. They operate in a collaborative, technology-enabled environment focused on measurable outcomes and exceptional patient experiences, and they are hiring for this role through Jobgether, an AI-powered job matching platform.