Transition Care Manager

Strive Health

Strive Health is built for purpose- to transform a broken kidney care system. We are fundamentally changing the lives of kidney disease patients through early identification and engagement, comprehensive coordinated care, and home-first dialysis. Strive’s model is driven by a high-touch care team that integrates with local providers and spans the entire care journey from CKD through ESRD, leveraging comparative and predictive data and analytics to identify patients at risk. Strive Health’s interventions significantly reduce the rate of emergent dialysis crash, cut inpatient utilization, and significantly improve patient outcomes and experience. Come join our journey as we create THE destination for top talent in the Healthcare community and set a new standard for how kidney care should be done.

Strive Care Partners 

Strive Care Partners (SCP) is a dedicated business unit within Strive Health that partners with nephrologists to share and succeed in global risk contracts with payors. SCP will benefit patients with CKD and ESKD through a comprehensive, patient-centered approach that enhances lives and local communities. SCP develops local market partnerships with nephrologists and provides them with the tools necessary to be successful in managing risk on their patients. Specifically, SCP delivers primary care services, specialized clinical programs, data integration and analytics, care teams, and administrative support services – all embedded within the nephrologist’s practice. SCP contracts with local market payors on the nephrologists’ behalf to take global risk on their CKD and ESKD patients and provides nephrologists with meaningful short-term and long-term financial incentives, including participation in shared savings and equity-based programs. 

Transition Care Manager

RN Care Manager – Transition of Care Management (TCM) The TCM RN works alongside Strive care coordinators and nurse practitioners to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for CKD and ESRD patients. The RN care manager will work specifically on Transition of Care Management efforts, to outreach patients who have been newly discharged from the in-patient setting within specified time requirements. The RN Care Manager will take every care management measure possible to help avoid patient complications and readmissions. The RN care manager will work in conjunction with care coordinators and social workers while acting as the clinical subject matter expert and resource for patients and their families, the local care team, and other healthcare professionals in regard to immediate patient follow-up and facilitation of needs post-discharge. Services to patients are generally provided telephonically.

• Identifies newly discharged patients and outreaches within 48 hours
• Assesses for immediate needs and identifies any signs and symptoms of potential complication
• Completes a comprehensive medication reconciliation
• Ensures patient understands all discharge instructions and newly prescribed medications
• Completes a full TCM Care Plan and ensures that it is shared with patient and patient’s entire care team
• Ensures that the patient has necessary follow-up visits scheduled with care team
• Collaborates with the care team to develop and or adjust the individualized and comprehensive care plan for the patient Identifies patient and/or clinic staff knowledge and understanding deficits regarding their specific program and situation.
• Provides the appropriate education, support and materials to facilitate informed decision making and understanding.
• Assesses patient conditions, in conjunction with the care team, such as the discovery of unreported medical and social conditions, or changes at home that may lead to adverse outcomes and ensures these concerns are referred to the appropriate sources for attention.
• Maintains and updates the appropriate program software to manage and record required information and data.
• Generates and analyzes reports as needed for management, identifying trends, anomalies and areas of concern.
• Adheres to company and clinical guidelines to identify, review, assess and allocate patients for program participation according to their identified needs
• Participates in process improvement activities.
• Collaborates with all levels of the clinical team to improve processes, communication, and team skills needed to provide the best care to our patients
• Utilizes clinical judgment, independent analysis, critical thinking skills, time management skills and detailed knowledge of case management program
• Meet in person with internal and/or external stakeholders to facilitate team and business priorities/opportunities. 
• Serve patients in person and in multiple care settings (e.g., patient home, clinics) in addition to virtual visits.   
• Monthly 5-10% of RN or NP charts will be audited to ensure quality care is being provided to our patients in accordance with our program description.  Performance management of clinical staff that are not meeting the quality audit expectations is a critical part of the clinical managers role.

Minimum Qualifications

• Graduate of an accredited school of nursing
• Bachelor's degree required; Master’s degree preferred
• 2 years’ nursing experience
• At least one (1) years complex care management, transitional care management, or equivalent experience in healthcare environment required.
• Current Registered Nurse (RN) - Must hold current licensure, or agree to immediately pursue licensure, in all the states which fall into the Strive region for which the Lead TCM RN is hired.
• Certification by a nationally recognized case/care management organization or agreement to obtain within 6 months of hire.
• Business travel

Preferred Qualifications

• Skilled and passionate caring for patients with complex needs
• Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes.
• Demonstrated experience and effectiveness in change agent role.
• Excels at developing strong patient/family relationships that fosters engagement and best outcomes for all aspects of Strive Health’s Model of Care
• Basic computer skills and proficiency in MS Word and Outlook required

Strive Health offers competitive compensation and benefits.  An annual performance bonus, determined by company and individual performance, is available for many roles and aligned to Strive Health guidelines. Learn more about our benefits here

Strive Health is an equal opportunity employer and drug free workplace. At this time Strive Health is unable to provide and work visa sponsorship. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Please apply even if you feel you do not meet all qualifications. If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talentacquisition@strivehealth.com

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