Chronic Care Management Nurse

The Chronic Care Manager (CCM) is responsible for coordinating care for patients with multiple chronic conditions, ensuring they receive comprehensive, continuous, and proactive support. This role focuses on improving health outcomes, reducing hospitalizations, and enhancing patient engagement through structured care planning, outreach, and collaboration with the clinical team.

This position requires a strong understanding of chronic disease processes, excellent communication skills, and the ability to work independently within CMS Chronic Care Management (CCM) model for RHC and PCMH. This position is full time, Monday through Friday, with no holidays, weekend, or on call requirements.

Essential Duties include (but not limited to):

· Identify eligible patients for CCM using various dashboards and registries.

· Conduct initial and ongoing patient assessments, including medical, functional, and psychosocial needs.

· Develop, implement, and update comprehensive, patient-centered care plans.

· Provide non-face-to-face care management services, ensuring required time thresholds are met.

· Initiate TOC outreach within required timeframes (typically 48–72 hours depending on payer).

· Conduct post‑discharge assessments including medication reconciliation, symptom review, red‑flag education, and follow‑up scheduling.

· Educate patients and caregivers on chronic conditions, self-management, and available resources.

• Serve as a primary point of contact for patient questions, concerns, and care navigation.
• Document all patient interactions in the EHR according to CMS billing and compliance standards.

· Track program metrics, patient engagement, and quality outcomes including accountable care organization (ACO) metrics.

· Assist with annual wellness visits, transitional care management, and population health initiatives as needed.

Qualifications Required:

• RN BSN strongly preferred, will consider an LPN with experience (please note starting rate listed is for an RN, rate would differ for an LPN).
• Preferred certification in chronic care Management or 2-3 years of clinic leadership/ case management experience.
• Computer literacy with Word, Excel and EMR (EPIC)
• Able to work a flexible schedule and coordinate multiple projects simultaneously when needed

Pay: From $30.23 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Work Location: In person

Salary : $30