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Case Manager - Intensive Home Care Program (Complex Case Management)

Devoted Health

Devoted Health

Arizona, USA · Remote
Posted on Monday, June 3, 2024

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

Job Description

A bit about us

We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being.

That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly.

We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.

A bit more about this role:

Devoted Medical Group was founded on the belief that if we treat each member like we would our loved ones, we can meaningfully improve healthcare experiences and outcomes for some of America’s most vulnerable patient populations. The Intensive Home Care (IHC) Program is at the heart of this goal: we are a highly collaborative, multidisciplinary team of physicians, nurse practitioners, case managers, social workers, community health workers, and outreach specialists united by our mission to build a better care delivery system for Devoted’s most complex members. Through a mixture of in-home and virtual interventions, we provide whole-person clinical, social and logistical support for patients with complex chronic conditions, frail elders, and patients at high risk of hospital admissions.

The IHC RN Case Manager is a critical part of the IHC care team, serving as both team quarterback and empowered patient advocate,ensuring the most vulnerable patients are supported, attended to, and enabled to live their best possible lives. To do so requires traditional case management roles and some broader team management roles.

The more traditional case management pieces include:

Ensuring smooth transitions of care for patients in the hospital or recently discharged, seeking to minimize readmissions

Providing telephonic and virtual longitudinal case management support for poorly controlled chronic illness

Facilitating chronic disease management including coaching patients and remote monitoring

Team management roles include:

Running weekly member rounds to ensure the entire IHC team is focused on the barriers of our most vulnerable patients

Leading Acute Clinical Episode Review (ACER) rounds with IHC Medical Directors to look at admissions and determine the level of predictability and actionability, in an effort to prevent future readmissions

Building relationships with key local market and internal stakeholders

Modeling excellent communication, documentation, efficiency, and critical thinking skills to the interdisciplinary team

In short, the case manager sews together the quilt that pieces all the fragments of the health system for the most complex patients.

Our ideal IHC case manager is caring, compassionate, solution-oriented and enthusiastic about providing an outstanding experience for Devoted Health’s members. They are committed to integrity, excellence, and empowering our most complex members to confidently navigate the healthcare system and live healthier lives. They are ready to innovate, adaptable to a continuously evolving startup environment, and willing to start scrappy, working with the whole Devoted family to create a revolution in how care is delivered.

Responsibilities will include:

Working with members

  • Engaging with high risk members to understand their needs, supported by technology and data tools

  • Conducting holistic assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and member values and preferences

  • Developing care plans in partnership with members and their caregivers and the IHC team - problems, goals, interventions - while continuously evaluating the member’s progress

  • Explaining complicated medical terms in plain language

  • Educating members on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence following a Red / Yellow / Green strategy

  • Preparing members for their inpatient and outpatient treatments

Working with other providers and resources

  • Building relationships with local key hospitals, skilled nursing facilities, home health agencies, specialists, and PCP groups in geographies served by IHC

  • Working closely with social workers and community health workers to address patients’ social determinants and support non-clinical case management functions

  • Coordinating post-treatment care and complex DME & Home Health needs

  • Collaborating closely with our PCP partners to coordinate care and deliver evidence based, effective, and accessible health care.

Improving how we work

  • Providing feedback and advice to help improve the operational processes, software tools, and data capabilities to improve how Devoted does transitions of care case management

  • Partnering with Devoted Medical Group leadership to continuously improve the Intensive HomeCare model

Attributes to success:

  • A desire to make a change in the healthcare experience: you love to serve and make a difference

  • You enjoy being on the phone caring for patients

  • Strong clinical skills that will help you understand what a patient needs to help her avoid poor health outcomes

  • Excellent organizational skills which you will use to prioritize and provide need-based levels of engagement with individual patients, communicate and coordinate care needs across various organizations, and ensure none of our members fall through the cracks

  • Being a key part of an interdisciplinary team of health professionals who help our patients address their barriers to a better life: understanding who on your team can best help a patient, which patients should the team be focused on, recognize when we are hitting barriers so the team can work together to resolve

  • The ability to learn quickly from past experiences and implement changes for improvement

  • You are comfortable working with technology and in a dynamic, startup environment

  • Comfort or interest in working remotely

Desired skills and experience:

Must haves:

  • An RN license in the area that will be served

  • A minimum of 4 years of RN experience

  • Prior case management experience

  • The ability to comfortably multi-task: you’ll be listening, talking and typing all at the same time

  • Team player mentality with a can-do attitude

  • Comfortable working with external stakeholders to advocate for our patients

Nice to haves:

  • Bilingual in English and Creole or Spanish

  • Health insurance experience, particularly Medicare Advantage

  • Prior experience working with a complex patient population

#LI-Remote

Our ranges are purposefully broad to allow for growth within the role over time. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered may depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

  • Employer sponsored health, dental and vision plan with low or no premium

  • Generous paid time off

  • $100 monthly mobile or internet stipend

  • Stock options for all employees

  • Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

  • Parental leave program

  • 401K program

  • And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.