About Us
We are a data-powered, performance-driven healthcare organization committed to excellence in every aspect of our work. Our mission is to make high-quality healthcare affordable, enhance patient health, and restore the joy of practicing medicine for providers. Guided by empathy and powered by AI and predictive analytics, we use a combination of remotely-embedded Healthguides™ and a centralized Managed Service Organization to strengthen connections between patients and providers. Led by physicians, we empower our partners to deliver top-notch healthcare, focusing on outcomes and value inside and outside the exam room for all patients.
Role Overview
In this role, you will collaborate with clinical teams to provide comprehensive case management and reinforce the bond between patients and their primary care physicians or medical practice staff. Your primary responsibility will be to assist patients in achieving their highest level of wellness. You will manage a specific patient population that includes individuals with complex medical conditions, socio-economic challenges, and/or mental health co-morbidities. Through assessment, planning, implementation, coordination, monitoring, and evaluation, you will optimize the patient's health status and ensure they receive the care and services they need. You will also work closely with a team of patient care navigators and other healthcare professionals to achieve the best possible outcomes for your patients, both clinically and financially.
This is a remote position with occasional travel required (10%-15%). We are currently considering candidates who live within 90 minutes of Houston or plan to relocate to the area.
Key Responsibilities
- Conduct comprehensive assessments of patients’ healthcare and psychosocial needs.
- Review and refine patient navigator interviews with patients to ensure accuracy.
- Develop, implement, and maintain individualized care plans in line with internal protocols and accreditation standards.
- Provide evidence-based clinical interventions aligned with care plan goals.
- Collaborate with patient navigators to manage non-clinical elements of the care plan, such as scheduling appointments, arranging transportation, or addressing other social determinants of health (SDOH).
- Perform ongoing outreach to patients, continuously monitor patient data, and adjust care plans as needed.
- Work with primary care providers to develop patient-specific escalation plans for managing acute but non-emergent exacerbations of chronic conditions.
- Educate patients about their conditions and treatment options.
- Advocate for patients, helping them access and engage with necessary services and resources that require clinical expertise.
- Follow up on referrals to services or resources.
- Maintain accurate and up-to-date documentation in the electronic health record as per protocol.
- Utilize evidence-based clinical protocols and guidelines, adhering to defined quality metrics.
Qualifications
- Current Registered Nurse (RN) license in good standing.
- At least 3 years of experience in RN Case Management within an outpatient setting.
- CCM certification is preferred; if not already certified, you must obtain CCM certification within 1 year of employment.
- Supervisory experience is a plus.
- Strong written and verbal communication skills, with the ability to interact empathetically with patients, families, and the interdisciplinary team.
- Proficient computer skills, with the ability to quickly learn multiple EMR and case management systems.
- Ability to meet accreditation and quality standards, including but not limited to NCQA and HEDIS.
- Bilingual in English and Spanish is a plus.
Benefits We Offer
While you’re dedicated to advancing value-based healthcare, we're here to ensure you have the support you need to care for yourself and your family. Here's what we offer:
- Work from Home: Enjoy the flexibility of a fully remote role, allowing you to focus on your professional goals and personal needs.
- Health and Wellness: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
- Financial Planning: Our 401(k) plan includes a 3% employer match to your 6% contribution.
- Peace of Mind: We provide Life and Disability insurance for those “just in case” moments, with additional voluntary Life options available to keep you and your loved ones protected.
- Support When You Need It: Our Employee Assistance Program (EAP) is here to help you navigate tough times.
- Work-Life Balance: We offer Flexible Time Off, tailored to meet your needs and the needs of the business.
- Family Support: Welcoming a new family member? We offer paid parental leave to give you the time you need.
- Learning and Growth: Your professional development matters to us, so we provide resources to help you advance your career.
Compensation
The base pay for this role ranges from \(80,000 to \)85,000 per year, paid bi-weekly. Final compensation decisions are based on various factors, including your skill set, years of relevant experience, education, location, and certifications.
Our Commitment to Equal Opportunity Employment
Diversity, inclusion, and belonging are central to our values. We are committed to being an equal-opportunity employer and make employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other legally protected status. We are dedicated to ensuring fair treatment and opportunities for all employees throughout their employment journey.
Security Responsibilities
This position requires adherence to all security policies and procedures to protect sensitive patient information and company intellectual properties. Additional security responsibilities may be defined by the hiring manager for specific roles.
Employment Type: Full-Time