Remote Transitions of Care (TOC) Nurse, Full-time (Arizona / Washington Residents ONLY)

Brilliant Care is a very innovative, fast-growing, mission-driven population health management company that assists with value based care initiatives. Our objective is simple: improve health outcomes and reduce total cost of care. We proactively identify at-risk hypertensive, diabetic and CHF patients and provide them with personalized access to a nurse care manager who works as an extension to the provider. Using high-touch care coordination and advanced remote technologies, we improve patient compliance and medication adherence while reducing unnecessary ER and hospital visits. Essentially, we help improve outcomes substantially, without heavy lift or any out-of-pocket costs for healthcare organizations.

Transitions of Care (TOC) Nurse assists the treatment team in evaluating discharge summaries. TOC Nurse position is a high paced position that requires timely outreach to patients discharged to review and discuss their discharge documents and coordinate and schedule care services.

Care Management: Analyze live discharge data to understand hospitalization history, discharge diagnosis and acuity level Connect with patients within 24 hours of discharge to review discharge documents and schedule follow up visit with provider within specific timeframes Provide quality outreach and education to decrease readmissions Escalate cases which require provider attention Excellent communication skills to ensure patient is clear on action items post-discharge Capture detailed and concise notes of all patient interactions Act as a resource to patients in enabling access to the provider and presenting information to the provider Possess ability to perform medication reconciliation Possess ability to connect easily and quickly with patients of varying demographics Provider & Practice Management: Possess ability to change workflow and processes as requested by provider or practice