[Hiring] RN Case Manager @Duly Health and Care

Role Description

The Remote TCM Nurse Care Manager collaborates with physicians, patients, caregivers, and interdisciplinary healthcare teams to support patients following hospital discharge. This role is responsible for engaging patients during the 30-day post-discharge period, completing clinical assessments, coordinating care transitions, facilitating timely follow-up care, and implementing interventions designed to reduce avoidable readmissions and improve patient outcomes. The Nurse Care Manager provides telephonic and virtual care management services while promoting safe, effective transitions across the continuum of care.

Essential Duties & Responsibilities

• Review hospitalization and discharge reports to identify patients eligible for Transitional Care Management services.
• Conduct post-discharge outreach, assessments, and enrollment activities in accordance with program requirements.
• Manage an assigned caseload of patients during the 30-day post-discharge period.
• Develop, implement, and monitor individualized care plans with measurable goals and interventions.
• Coordinate follow-up appointments, medication reconciliation, and post-discharge services.
• Collaborate with providers, office staff, hospitals, skilled nursing facilities, home health agencies, and community resources to facilitate care transitions.
• Identify and address barriers to care, including social determinants of health.
• Educate patients and caregivers regarding discharge instructions, disease management, and symptom escalation.
• Maintain accurate and timely documentation within the EMR and care management platforms.
• Monitor patients for risk factors associated with avoidable readmissions and escalate concerns appropriately.
• Collaborate with care management, quality, and population health teams to support value-based care initiatives.
• Perform other duties as assigned.

Qualifications

• Knowledge of transitional care management, care coordination, and readmission prevention principles.
• Strong communication, assessment, and critical thinking skills.
• Ability to work independently in a remote environment.
• Strong organizational and time-management abilities.
• Proficiency with EMR systems, care management platforms, and Microsoft Office.
• Knowledge of community resources and social determinants of health.

Requirements

• Current unrestricted Registered Nurse (RN) license required.
• Associate Degree in Nursing (ADN) required, Bachelor of Science in Nursing preferred.
• CCM, ACM, or equivalent certification preferred.
• Minimum two years of clinical nursing experience required.
• Two years of case management, care coordination, transitional care management, or population health experience preferred.
• Remote or telephonic care management experience preferred.

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

Company Description

At Duly Health and Care, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.