Care Manager, RN, US-Remote

2025-2615 At Curana Health, we’re on a mission to radically improve the health, happiness, and dignity of older adults—and we’re looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we’ve grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. If you’re looking to make a meaningful impact on the senior healthcare landscape, you’re in the right place—and we look forward to working with you. For more information about our company, visit CuranaHealth.com. Summary The Care Manager, TCM delivers telephonic care management for Curana patients during transitions, such as discharge from long-term care (LTC) facilities or senior living communities to acute care hospitals. They coordinate with hospital case managers and community staff for effective discharge planning, collaborate with providers and interdisciplinary teams, and work to ensure quality care and reduce preventable rehospitalizations. Essential Duties & Responsibilities Care Coordination • Contact patients within two (2) business days of hospital discharge to assess needs and initiate the transitional care process. • Schedule and coordinate timely follow-up appointments with a Curana provider and specialist within the required timeframes. • Perform telephonic outreach to assess medication reconciliation, medical, or social needs. • Identify gaps in care and address barriers to follow-up or treatment adherence. Patient Support & Education • Perform transitional care management health assessments. • Serve as a health coach to educate the patients and/or caregivers on discharge instructions, medication regimens, and chronic disease management. • Provide referrals to community-based services, palliative care, or behavioral health services as needed. • Apply clinical judgment to incorporate strategies that reduce patient risk factors and barriers. Communication Support • Communicate patient health updates to the Curana providers and support staff. • Coordinate with the Care Management pod to coordinate provider TCM visit. Qualifications • Strong clinical knowledge and understanding of chronic and acute conditions. • Familiarity with CPT codes 99495 and 99496 requirements. • Ability to identify red flags during post-discharge recovery. • Familiarity with discharge summaries, medication changes, and follow-up needs. • Demonstrated strategic thinking, process improvement, innovative thinking and team management expertise • Ability to communicate with patients and caregivers in an effective and caring manner. • Effective written and verbal communication skills. • Proficient in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. Required Education & Experience: • Must hold an active unrestricted compact RN or LPN nursing license. • Ability to obtain additional state licenses, as needed • 2+ years of experience in nursing is required. Care settings may include inpatient, outpatient, or skilled nursing facilities. Preferred Qualifications: • CCM certification (strongly preferred) • Experience working with Electronic Health Records • Transition of care experience desired. Travel Requirements: • 100% remote position requires a reliable high-speed internet connection. Apply tot his job Apply To this Job