RN Care Manager, SNF - Indiana

Overview

What We Strive For At Strive Health, we’re driven by a purpose: transforming the broken kidney care system. Through early identification, engagement, and comprehensive coordinated care, we significantly improve outcomes for people with kidney disease, reducing emergency dialysis and inpatient utilization. Our high-touch care model integrates with local providers and uses predictive data to identify and support at-risk patients along their entire care journey.

We embrace diversity, celebrate successes, and support each other, making Strive the destination for top talent in healthcare. Join us in making a real difference.

• Hybrid-Remote Flexibility – Work from home while fulfilling in-person needs at the office, clinic, or patient home visits.
• Comprehensive Benefits – Medical, dental, and vision insurance, employee assistance programs, employer-paid and voluntary life and disability insurance, plus health and flexible spending accounts.
• Financial & Retirement Support – Competitive compensation with a performance-based discretionary bonus program, 401k with employer match, and financial wellness resources.
• Time Off & Leave – Paid holidays, vacation time, sick time, and paid birth giving, bonding, sabbatical, and living donor leaves.
• Wellness & Growth – Family forming services through Maven Maternity at no cost and physical wellness perks, mental health support, and an annual professional development stipend.

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 role also plays a key role in discharge planning for patients in skilled nursing facilities, acute care, and post-acute care settings, helping to ensure safe transitions and reduce readmissions. This position reports to the Sr. Manager, Transitional Care Management.

• 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.
• Performs proactive outreach to patients and providers following TCM guidelines to evaluate status and address needs.
• Monitors patient hospitalizations and SNF admissions, coordinating with internal and external care team members to ensure seamless information flow.
• Participates in discharge planning for patients transitioning from Skilled Nursing Facilities, acute care, or post-acute facilities, ensuring follow-up care is arranged, medications are reconciled, and the care plan is communicated to all necessary providers.
• 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…