RN Care Manager- Transition of Care Management (TCM)- Remote

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Overview

Strive Health

Strive Health is built for purpose- to transform a broken kidney care system. We are fundamentally changing the lives of kidney disease patients through early identification and engagement, comprehensive coordinated care, and home-first dialysis. Strive's model is driven by a high-touch care team that integrates with local providers and spans the entire care journey from CKD through ESRD, leveraging comparative and predictive data and analytics to identify patients at risk. Strive Health's interventions significantly reduce the rate of emergent dialysis crash, cut inpatient utilization, and significantly improve patient outcomes and experience. Come join our journey as we create THE destination for top ta lent in the Healthcare community and set a new standard for how care kidney should be done.

RN Care Manager- Transition of Care Management (TCM)

RN Care Manager - Transition of Care Management (TCM) The TCM RN works alongside Strive care coordinators and nurse practitioners to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. The RN care manager will work specifically on Transition of Care Management efforts, to outreach patients who have been newly discharged from the in-patient setting within specified time requirements. The RN Care Manager will take every care management measure possible to help avoid patient complications and readmissions. The RN care manager will work in conjunction with care coordinators and social workers while acting as the clinical subject matter expert and resource for patients and their families, the local care team, and other healthcare professionals in regard to immediate patient follow-up and facilitation of needs post-discharge. Services to patients are generally provided telephonically.

Essential Functions

  • Identifies newly discharged patients and outreaches within 48 hours
  • Assesses for immediate needs and identifies any signs and symptoms of potential complication
  • Completes a comprehensive medication reconciliation
  • Ensures patient understands all discharge instructions and newly prescribed medications
  • Completes a full TCM Care Plan and ensures that it is shared with patient and patient's entire care team
  • Ensures that the patient has necessary follow-up visits scheduled with care team
  • Collaborates with the care team to develop and or adjust the individualized and comprehensive care plan for the patient Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation.
  • Provides the appropriate education, support and materials to facilitate informed decision making and understanding.
  • Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention.
  • Maintains and updates the appropriate program software to manage and record required information and data.
  • Generates and analyzes reports as needed for management, identifying trends, anomalies and areas of concern.
  • Adheres to company and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs
  • Participates in process improvement activities.
  • Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients
  • Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program

Qualifications

Minimum Qualifications

  • Graduate of an accredited school of nursing
  • Bachelor's degree required; Master's degree preferred
  • 2 years' nursing experience
  • At least one (1) years complex care management, transitional care management, or equivalent experience in healthcare environment required.
  • Current Registered Nurse (RN) - Must hold current licensure, or agree to immediately pursue licensure, in all the states which fall into the Strive region for which the Lead TCM RN is hired.
  • Certification by a nationally recognized case/care management organization or agreement to obtain within 6 months of hire.

Preferred Qualifications

  • Skilled and passionate caring for patients with complex needs
  • Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes.
  • Demonstrated experience and effectiveness in change agent role.
  • Excels at developing strong patient/family relationships that fosters engagement and best outcomes for all aspects of Strive Health's Model of Care
  • Basic computer skills and proficiency in MS Word and Outlook required

Strive Health is an equal opportunity employer and drug free workplace. At this time Strive Health is unable to provide and work visa sponsorship. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Please apply even if you feel you do not meet all qualifications . If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to [email protected]

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Technology we use

  • Engineering
  • Product
  • Sales & Marketing
  • People Operations
    • JavaLanguages
    • JavascriptLanguages
    • PerlLanguages
    • PythonLanguages
    • RLanguages
    • ScalaLanguages
    • SqlLanguages
    • jQueryLibraries
    • HadoopFrameworks
    • Node.jsFrameworks
    • SparkFrameworks
    • TensorFlowFrameworks
    • Microsoft SQL ServerDatabases
    • MySQLDatabases
    • SQLiteDatabases
    • Microsoft AzureServices
    • AxureDesign
    • CanvaDesign
    • AsanaManagement
    • ConfluenceManagement
    • JIRAManagement
    • Microsoft ProjectManagement
    • SmartsheetManagement
    • DocuSignCRM
    • SalesforceCRM
    • Salesforce HealthcloudCRM
    • Microsoft TeamsCollaboration
    • SlackCollaboration

Location

Our office is in the heart of downtown Denver. We are a few blocks from the 16th Street Mall, which has lots of bars, restaurants and shops!

An Insider's view of Strive Health

What’s the vibe like in the office?

In the Denver office we do occasional Happy Hours and office lunches. These are a great opportunity to network and connect across departments and spend time with colleagues who are visiting from out of town. It is a nice bonus that our office has incredible 360 views across Denver!

Jane

Director, Talent Development

How do you collaborate with other teams in the company?

Creating strong and trusting relationships through each conversation daily! In my role in Finance, I believe that effective collaboration and communication is crucial to both creating a great work environment and fostering new, strong relationships. Through this collaboration, it will allow Strive to succeed towards achieving our long-term goals.

Nick

Sr. Manager, National Finance

How has your career grown since starting at the company?

My career has grown immensely since starting with Strive Health. I joined the company in an entry level position and was presented with numerous opportunities to grow into more senior technical and managerial roles within my first two years at the company. The culture at Strive Health places an emphasis on personal growth and development.

Sam

Manager, Data Analytics

How do you empower your team to be more creative?

Ownership. A critical part of the team is that people know what they should be working on and what they are accountable for delivering. This gives them a chance to build the rapport with their non-technology counterparts to best understand the business components that relate to their expertise. It’s beautiful to see team members become creative.

Matt

Chief Technology Officer

What makes someone successful on your team?

Team player, innovative, problem solver, and drive to learn are just a few! The analytics team works closely as a team and across various business units to build innovative and creative solutions to solve complex questions. The team works together to review code, attend learning days, and share ideas from new projects or training.

Leona

Sr. Director, Data Analytics

What are Strive Health Perks + Benefits

Strive Health Benefits Overview

Our Total Rewards program supports our commitment to holistic employee wellness, growth and development, recognition of driving business outcomes, consistency and equity.

Physical Wellbeing
Strive offers insurance aligned with our core value of Care, so your health insurance starts the day you join Strive! We offer a variety of medical and dental plans and one comprehensive vision plan. Full-time Strivers are also provided employer-paid life insurance, short-term disability and long-term disability coverages upon hire. Strivers also have access to our fitness wellbeing platform, Gympass.

Career Wellbeing
All Strivers can leverage annual professional development reimbursements to pursue classes, certifications or conferences. A 10% tuition discount is available through the CSU Global Campus.

Financial Wellbeing
With competitive pay, a 401k employer match and unlimited access to certified financial professionals through Origin Financial, Strivers are empowered to manage their finances and meet their personal goals.

Inner Wellbeing
Your mental health matters! Strivers have access to Headspace, Striver-led meditation sessions, two comprehensive employee-assistance programs and annual wellbeing days off to focus on personal wellbeing. Strive has also pledged to be a stigma-free workplace.

Family & Community Wellbeing
To support life outside of work, Strivers enjoy generous paid time off, including holidays, vacation days, sick days and volunteer days. Strivers have access to paid parental leave (4 weeks), paid birth-giving leave (12 weeks), paid sabbatical leave (4 weeks) and paid living-donor leave (8 weeks). Strive also partners with Carrot Fertility to provide reproductive and adoption support.

Culture
Volunteer in local community
Partners with nonprofits
Open door policy
OKR operational model
Team based strategic planning
Open office floor plan
Employee resource groups
Employee-led culture committees
Hybrid work model
Employee awards
Flexible work schedule
Remote work program
Diversity
Highly diverse management team
Mandated unconscious bias training
Diversity manifesto
Mean gender pay gap below 10%
Diversity employee resource groups
Hiring practices that promote diversity
Diversity recruitment program
Health Insurance & Wellness Benefits
Flexible Spending Account (FSA)
Disability insurance
Dental insurance
Vision insurance
Health insurance
Life insurance
Pet insurance
Wellness programs
Mental health benefits
Wellness days
Financial & Retirement
401(K)
401(K) matching
Company equity
Performance bonus
Pay transparency
Child Care & Parental Leave Benefits
Generous parental leave
Family medical leave
Fertility benefits
Vacation & Time Off Benefits
Unlimited vacation policy
Generous PTO
Paid volunteer time
Sabbatical
Paid holidays
Paid sick days
Flexible time off
Floating holidays
Bereavement leave benefits
Office Perks
Commuter benefits
Company-sponsored outings
Free snacks and drinks
Some meals provided
Company-sponsored happy hours
Onsite office parking
Recreational clubs
Home-office stipend for remote employees
Mother's room
Professional Development Benefits
Job training & conferences
Lunch and learns
Promote from within
Mentorship program
Continuing education stipend
Continuing education available during work hours
Customized development tracks
Paid industry certifications
Personal development training

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