What are the responsibilities and job description for the Chronic Care Management (CCM) Nurse position at Medical Associates of the Shoals PC?
Chronic Care Management (CCM) Nurse - Full time
- Medical Associates of the Shoals
Medical Associates of the Shoals is looking for a compassionate, organized, and patient-focused RN to join our team as a Chronic Care Management (CCM) Nurse.
This is a rewarding opportunity for a nurse who enjoys building relationships with patients, providing education, coordinating care, and helping patients better manage their chronic conditions.
What You'll Do
- Manage a caseload of patients with two or more chronic conditions.
- Develop and monitor individualized care plans.
- Conduct monthly patient outreach by phone or in person.
- Build strong, ongoing relationships with patients and caregivers.
- Help patients set health goals and manage medications.
- Educate patients on chronic disease management, preventive care, and healthy lifestyle changes.
- Coordinate referrals, home health services, and community resources.
- Work closely with physicians and clinical staff to address changes in patient needs.
- Monitor ER visits and hospitalizations and follow up with patients as appropriate.
- Accurately document patient interactions and care activities in the EHR.
- Ensure CCM documentation meets program and billing requirements.
- Serve as a consistent point of contact and resource for patients enrolled in the CCM program.
What We're Looking For
- Current RN license in Alabama.
- At least 2 years of experience in chronic disease management, case management, or primary care preferred.
- Strong understanding of common chronic conditions such as diabetes, hypertension, COPD, CHF, and depression.
- Excellent communication and patientengagement skills.
- Highly organized and detailoriented.
- Comfortable using electronic health records and basic computer systems.
- Ability to work independently while collaborating effectively with providers and the clinical team.
- Experience with Medicare Chronic Care Management programs and billing requirements is a plus, but not required.
Why Join Medical Associates of the Shoals?
If you enjoy nursing but want the opportunity to build meaningful, long-term relationships with patients rather than simply seeing patients for a single visit, this could be a great fit.
As a CCM Nurse, you'll have the opportunity to make a real difference by helping patients manage chronic conditions, stay engaged in their care, and avoid unnecessary hospital visits.
Join a team that values compassionate patient care, teamwork, and making a lasting difference in the lives of our patients.**
- Apply today to become part of Medical Associates of the Shoals!
- Medical Associates of the Shoals is an Equal Opportunity Employer.
Salary : $46,683 - $63,903