Company Description

Job Description

• Conduct in-depth telephonic assessments of medical, psychosocial, and social needs.
• Review and update medical histories, including medications, chronic conditions, and preventive care.
• Develop individualized care plans and guide patients through treatment goals and care options.
• Provide empathetic, evidence-based education on chronic disease management and preventive health.
• Monitor progress by phone, adjust care plans, and ensure patients stay connected to providers.
• Complete Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision.
• Partner with Healthguides who support non-clinical needs like scheduling, transportation, food assistance, and social determinants of health resources.
• Perform proactive outreach and timely follow-ups to maintain continuity of care and patient engagement.
• Advocate for patients, helping them access the right resources at the right time.
• Document clearly and accurately in the EHR and care-management systems during and after calls.
• Support quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions.
• Participate in virtual meetings, ongoing education, and clinical training to stay current with care standards.
• Use multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients.
• Collaborate in AI-driven outreach programs that help connect with vulnerable populations.
• Protect patient privacy in a secure, private home workspace.
• Perform additional responsibilities as needed to support patients and the care team.

Qualifications

• Active Compact Registered Nurse license in good standing is required.
• 3+ years of RN Case Management experience, preferably in outpatient or ambulatory care.
• Strong critical-thinking and problem-solving skills to anticipate barriers and drive care forward.
• Ability to work independently, manage multiple priorities, and make sound clinical decisions remotely.
• Outstanding communication—warm, clear, confident, and patient-focused.
• Excellent telephonic interviewing skills and ability to document accurately in real time.
• High comfort level with technology: EMRs, care-management systems, multi-screen workflow, Microsoft Office, and telecommunication tools.
• Understanding of accreditation and quality standards (NCQA, HEDIS).
• A quiet, private home office suitable for patient calls and handling PHI.
• Alignment with Guidehealth policies, clinical protocols, and compliance standards.

• BSN and Case Management certification preferred.

Additional Information & Benefits

• Fully remote work with flexibility and reduced commuting.
• Comprehensive medical, dental, and vision plans.
• 401(k) with a 3% employer match to a 6% contribution.
• Life and disability insurance and voluntary life options.
• Employee Assistance Program (EAP).
• Paid time off and paid parental leave.
• Professional learning and development resources.