Clinical Care RN

Jaan Health is a leading AI-based care management company serving healthcare providers. For nearly a decade, the company has leveraged its easy-to-use, proprietary technology to enable health systems, medical groups, and ACOs to deliver high-quality, high-ROI proactive care to hundreds of thousands of previously underserved patients.

Phamily, the company's core technology platform, has transformed chronic disease management with clinically tested AI and easy-to-use technology that enables physicians and care teams to offer high-touch, individualized patient care that has been proven to reduce investment in extra labor and the overall cost of care.  Phamily helps ensure healthcare providers are compensated fairly for providing high-quality care between office visits, while improving the lives of patients with chronic diseases. Learn more at phamily.com.

We are seeking a compassionate, organized, and tech-savvy Clinical Care RN to support patients in our text-based Advanced Primary Care Management (APCM) program. This role focuses on delivering proactive, high-quality care through digital communication tools, driving better health outcomes for our patient populations. Ideal for healthcare professionals who thrive in a virtual care setting, value patient engagement, are passionate patient advocates and are skilled in critical thinking and care coordination.

• →Monitor and respond to patient messages and check-ins in a timely, compassionate, and professional manner
• →Identify, assess, and triage clinical concerns, SDOH needs, and care coordination barriers
• →Develop and update personalized care plans for patients; help educate and motivate patients to adhere to the care plan
• →Oversee the clinical quality of the team, by analyzing data or trends to manage direct reports, and help train, orient, and onboard new and tenured staff, and improve overall outcomes
• →Develop, implement, and revise care coordination workflows, policies or protocols to support the evolution of the care model to improve efficiency and scalability
• →Lead quality improvement initiatives, complete case review and chart audits, and host team meetings
• →Identify and troubleshoot issues that arise during new program iterations, escalating to leadership when there are critical impacts or opportunities for system-wide improvements
• →Identify and execute in improving workflows with new tools and AI. 
• →Collaborate with CMAs, LPNs/RNs, NPs, and Social Workers to ensure timely escalation and follow-through

• Registered Nurse with active, unrestricted compact license required with 4+ years of experience in a care management or clinical care coordination role (primary care, chronic care management, home health, etc.)
• Previous experience creating policies, procedures, and/or clinical processes 
• Strong critical thinking and problem-solving skills in a fast-paced environment
• Ability to independently manage a digital patient panel and prioritize escalations effectively
• Excellent written communication and documentation skills
• Comfort using EMRs, care coordination platforms, digital messaging tools and fast learner of new technologies
• Must have access to reliable internet and a secure/private environment
• This role may require travel of up to 10%, including potential overnight travel 

• Bilingual (Spanish) is a bonus but not required
• Knowledge of Medicare CCM/APCM programs a plus

Phamily is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, genetics, veteran status, sexual orientation, gender identity or expression, or any other legally protected status.