Registered Nurse - Chronic Care Management

Registered Nurse - Chronic Care Management

The Chronic Care Management (CCM) Nurse is responsible for providing coordinated, comprehensive care management services to patients with chronic conditions. Working remotely, the CCM Nurse will assist patients in managing their healthcare needs, with a focus on improving outcomes and reducing hospital readmissions. This role will include developing personalized care plans, coordinating care with providers, and offering ongoing support and education to help patients manage their conditions.

The position is open to both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) with relevant experience.

Care Coordination:

• Develop and implement individualized care plans for patients with two or more chronic conditions.
• Collaborate with primary care providers, specialists, and other healthcare professionals to ensure seamless care coordination.
• Facilitate care transitions, such as from hospital to home, to minimize readmission risk.

Patient Support:

• Conduct regular remote check-ins with patients to assess their needs, review medications, and offer education on managing chronic diseases such as diabetes, hypertension, COPD, heart failure, etc.
• Provide counseling on lifestyle modifications, medication adherence, and symptom management to improve patients' quality of life.
• Monitor patients’ progress and respond to emerging needs by adjusting care plans as necessary.

Documentation & Compliance:

• Maintain accurate and up-to-date records of all patient interactions, care plans, and services provided.
• Ensure compliance with Chronic Care Management (CCM) billing requirements, following Medicare and organizational guidelines.
• Track patients' eligibility for CCM services and ensure appropriate consent forms are signed and maintained.

Health Coaching & Education:

• Educate patients and their caregivers on chronic disease management, helping them understand their conditions, medications, and recommended treatments.
• Provide patients with resources and tools to improve self-management and promote healthy lifestyle changes.

Technology Use:

• Utilize the organization’s care management software and electronic health records (EHR) to document care, track patient progress, and coordinate services.
• Engage patients via phone, video calls, and digital messaging platforms as needed to provide remote care.

Qualifications: 

• Minimum of 2 years of nursing experience, preferably in chronic disease management, care coordination, case management, or population health.
• Associate's or Bachelor's degree in nursing or a related field from an accredited program.
• Experience in a remote nursing or telehealth role is preferred.
• Current and valid Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice.