RN Care Manager, Transitional Care Management - Central Time Zone

What You’ll Do 

Strive’s RN Care Managers in Transitional Care Management serve as specialized clinical resources for patients with complex Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) as they transition between care settings. This role supports safe, effective, and timely transitions by applying the Coleman Model of transitional care and working closely with patients, families, and interdisciplinary care teams. 

RN Care Managers ensure compliance with NCQA accreditation standards through accurate documentation, clinical expertise, and quality-driven care coordination. They play a critical role in minimizing readmissions and improving patient outcomes across the care continuum. This position reports to the Manager of Transitional Care Management. 

The Day to Day 

• Works closely with the care team to craft personalized and thorough care plans addressing the clinical and non-clinical needs of each patient. 

• Conducts regular assessments virtually to detect undisclosed medical or social issues and changes in the home environment that could pose risks, promptly referring such matters to the appropriate channels for resolution. 

• Perform proactive outreach to patients and providers following TCM guidelines to evaluate status and address needs 

• Manages a diverse patient panel, swiftly and accurately evaluating individual needs while adhering to NCQA standards for case management. 

• Communicates updates to the care team and family members, identifying gaps in patient understanding of their health status and delivering tailored education and resources to promote informed decision-making. 

• Acts as a liaison with dialysis facilities, conveying care plan updates to facilitate smooth transitions in care, and maintains accurate program software records. 

• Leverages Strive data platforms to identify trends, anomalies, and areas requiring focus. 

• Provides culturally sensitive care to meet the diverse needs of Strive patients, fostering collaboration and communication among all clinical team members to enhance care provision. 

• Utilizes clinical judgment, analytical skills, regular and predictable attendance, and comprehensive knowledge of case management programs to deliver high-quality care. 

• Participate in quality improvement initiatives and regional interdisciplinary team discussions to enhance care coordination, known as TCM rounds. 

Minimum Qualifications 

• Associate’s degree from accredited school of nursing 

• Current Registered Nurse (RN) license in the state of practice 

• 3+ years combined of related education, experience, or certification 

• Current BLS or CPR Certification required   
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms. 

Preferred Qualifications 

• 3+ years experience in nephrology, ER, ICU, Cardiac, or Ambulatory Complex case management nursing  

• Certified Case Manager (CCM) certification preferred 

• Proficiency in computer skills including Microsoft 365 Suite (word, outlook, excel) due to working in a hybrid-remote environment 

About You 

• Experience developing strong patient and family relationships that foster engagement and best outcomes for all aspects of Strive Health’s Model of Care  

• Demonstrated experience with proactively contacting patients and/or clinic on a frequent basis to assess both clinical and non-clinical needs 

• Proficiency with documenting and navigating electronic medical records (EMR) and care plan management 

Annual Salary Range: $74,000.00-$90,000.00