Your Role

You will collaborate with an assigned panel of physicians, advanced practice providers (APP), and ancillary team members to manage patients’ specialized needs based on their individual conditions. Your job duties will include taking full ownership of patients within your panel, with an additional focus on patients with complex chronic conditions, serious illness, or advanced frailty. You will perform assessments to identify member needs based on their values, goals and preferences. From these assessments, you will develop comprehensive, patient-centered care plans for each member. These care plans will be used to coordinate patient care delivery with Honest clinicians, network providers, contracted vendors, and community-based services. This work takes place remotely alternating with potential opportunities to visit aligned practices in your assigned areas

Primary Functions Include:

• Quickly build empathetic relationships with patients and families.
• Evaluate and identify patients’ needs based on their respective values, goals, and preferences, then translate these needs into clinical needs.
• Evaluate patients clinical and social needs through targeted assessments and medication reconciliation to assist in the development of a physician drive, patient-centered plan of care.
• Engage with patients in the immediate post discharge phase to coordinate care including facilitating primary care appointments, specialty appointments, durable medical equipment (DME) and vendor services all while continuing to support patients clinical and social needs.
• Interface with primary care physicians, advanced practice providers (APP), specialists, and various disciplines on the development of case management plans/programs.
• In conjunction with the physician/APP, implement care/treatment plans by coordinating access to health services across multiple providers/ disciplines.
• Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources.
• Effectively coordinate patient admissions and discharges from hospitals or skilled nursing facilities via coordination with respective facility clinicians and case managers.
• Build relationships across network hospitals, SNFs, home health companies, and DME vendors within the respective community.
• Monitor and evaluate the effectiveness of the case management plans based on quality and cost drivers and modify as necessary.
• Act as a patient advocate and educator to assure that the patient has the knowledge to care for his/her condition and patient is educated and empowered to be responsible for participating in the plan of care.
• Develop individualized patient/family education plans focused on self-management and deliver patient/family education specific to a disease state.
• Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources.
• Participate in data collection and analysis of clinical outcomes of care and customer satisfaction standards. Participate in the formulation and implementation and monitoring of action strategies and outcomes of care or customer service. Ensure that accurate records are maintained of the care associated with each patient.
• Actively participate in huddles, interdisciplinary team (IDT) sessions, and patient case conferences.
• Commendably represents Honest to patients, their families, and the community.
• Perform other related responsibilities as assigned.

How You Qualify

You reviewed the Who You Are section of this job posting and immediately felt the need to read on. This makes you a match for our innovative culture. You accept things change quickly in a startup environment and are willing to pivot quickly on priorities.

• Must have reliable access to high-speed internet to ensure seamless remote work communication and productivity
• Current Registered Nurse license is required; Bachelor’s of Science in Nursing preferred
• Certified Case Manager (CCM) credential preferred
• 3+ years of clinical practice in a hospital, clinic, home care, or nursing home setting highly preferred
• Case management experience with a senior population preferred
• Disease management and/or physician office experience highly preferred
• You are able to arrange travel to various work sites as needed, as well as possess and maintain a valid driver's license in your state of residence and motor vehicle insurance

The base pay range for this role is $76,660.00 - $88,000.00. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, and organizational needs. Base pay is just one piece of the total rewards program offered by Honest. Eligible roles also qualify for short-term incentives and a comprehensive benefits package.