Remote RN Chronic Care Management

Job Description

CCM RN Job Summary We are seeking a dedicated and energetic Remote Registered Nurse (RN) specializing in Chronic Care Management to join our dynamic healthcare team. In this vital role, you will provide comprehensive remote nursing care to patients with complex, long-term health conditions, ensuring they receive personalized support and effective management of their chronic illnesses. Your expertise will help improve patient outcomes, enhance quality of life, and promote adherence to care plans—all from the comfort of your home. This position offers an exciting opportunity to make a meaningful difference in the lives of diverse patient populations while working flexibly in a remote setting. Duties

• Initial patient outreach to qualified patients which includes:
• Assistance with Patient enrollment,
• Initial care plan development and provision to patients
• Full documentation of initial events
• Conduct monthly non-face-to-face chronic care coordination: chronic care management patient encounters
• Conduct thorough patient assessments via telehealth, including vital signs, medication reconciliation, and symptom review
• Educate patients and caregivers on disease management, medication use, lifestyle modifications, and preventive health strategies
• Coordinate with healthcare providers, specialists, and community resources to ensure seamless continuity of care
• Monitor patient progress through EMR (Electronic Medical Record) systems such as Epic, Cerner, or Athenahealth, etc.
• Document all interactions accurately in compliance with HIPAA regulations and organizational standards
• Triage incoming patient inquiries to determine urgency and appropriate follow-up actions
• Support patients managing complex conditions such as diabetes, heart failure, COPD, or post-surgical recovery
• Facilitate medication reconciliation and administration guidance
• Assist with discharge planning and long-term care coordination for patients transitioning between hospital, rehab, or home environments Skills
• Bilingual preferred
• Experience in Telephonic patient support preferred
• Proven experience with EMR/EHR systems such as Epic, Cerner, or Athenahealth for documentation and patient management
• Strong knowledge of chronic disease processes including cardiology (e.g., cardiac catheterization), nephrology (dialysis), pulmonology (ventilator management), and geriatrics
• Experience working with diverse populations including seniors in assisted living or nursing homes; patients with developmental disabilities; memory care; hospice & palliative medicine; behavioral health
• Ability to perform comprehensive patient assessments focusing on physiology knowledge and diagnostic evaluation skills
• Skilled in medication administration protocols
• Knowledge of medical coding systems such as ICD-10/ICD-9/CPT for accurate documentation and billing purposes
• Excellent triage skills to prioritize urgent cases effectively within a remote environment
• Familiarity with infection control practices
• Strong communication skills to educate patients effectively on health coaching topics like nutrition, pain management, or family planning Required: · RN BSN – Multistate preferred · Must have own computer and consistent access to high-speed internet · Must have own smart phone · Home Office working environment - maintaining Medicare Compliance · Self-motivated This role is ideal for registered nurses passionate about providing high-quality remote care across multiple specialties. If you thrive in a fast-paced environment that values innovation and compassionate patient engagement—while working from home—this is your next great opportunity! Pay: Up to $43.00 per hour Application Question(s):
• Have you ever worked remotely? Language:
• Spanish (Preferred)
• Haitian Creole (Preferred)
• French (Preferred) Work Location: Remote Apply tot his job

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