Remote RN Care Manager: Care Coordination & Transitions

ArchWell Health; Sarasota (FL); Hybrid; USD 70,000 - 95,000; Full time

Job summary

ArchWell Health is seeking a Nurse Care Manager to coordinate care for patients with acute and chronic conditions, guiding them from our centers into post-acute and home settings. You will co-create care plans with the team and execute them to achieve quality outcomes and regulatory compliance.

The role emphasizes care coordination, education, and proactive engagement using motivational interviewing, with opportunities to work remotely as part of a national network.

Qualifications

• Associate degree in Nursing is required.
• BSN or RN with related bachelor preferred.
• Active, unrestricted RN license required.
• Willingness to obtain RN license in other states.
• Minimum 2 years clinical work experience.
• 1 year utilization review/home health/discharge planning experience preferred.
• 1 year case management experience in acute or ambulatory settings preferred.
• Certified Case Manager certification preferred.
• Knowledge of ICD-10/CPT/HPCS codes and CMS/HEDIS preferred.

Responsibilities

• Establish a trusting relationship with patients, families, and/or caregivers.
• Collaborate with clinical staff and other care team members to achieve patient goals.
• Reduce network costs by driving referrals to preferred groups and identifying excessive referral requests.
• Identify high-risk/complex patients.
• Assess physical, functional, social, psychosocial, environmental, learning, and financial needs and develop a comprehensive, individualized care plan based upon identified needs.
• Perform case management following the nursing process and standards of practice.
• Provide patient education, care coordination, and other interventions to help patients achieve health goals.
• Utilize Motivational Interviewing to build patient engagement.
• Evaluate progress toward patient's goal achievement.
• Communicate telephonically with hospital case managers, PT, social workers, patients, and families/caregivers to facilitate a safe discharge plan.
• Manage and plan for transitions of care.
• Conduct transitions of care assessment/screening, medication reconciliation, and care coordination following discharge to home.

Skills

Care plan development

Case management

RN licensure

Clinical coordination

Communication skills

Remote work capability

Microsoft Office

Bilingual Spanish

Education

Associate degree in Nursing

BSN or RN with related bachelor preferred

Active RN license in-state

CCM certification preferred

Tools

EMR systems

Microsoft Office

Job description

ArchWell Health is seeking a Nurse Care Manager to coordinate care for patients with acute and chronic conditions, guiding them from our centers into post-acute and home settings. You will co-create care plans with the team and execute them to achieve quality outcomes and regulatory compliance.

The role emphasizes care coordination, education, and proactive engagement using motivational interviewing, with opportunities to work remotely as part of a national network.