Registered Nurse – Care Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Prepare detailed Annual Wellness Visit charts to enhance provider efficiency and ensure CMS compliance.

• Review patients' medical, surgical, and family histories, medication lists and adherence, preventive screenings, immunizations, as well as cognitive, functional, and depression assessments during virtual Zoom visits.

• Identify overdue screenings, risk factors, and care gaps prior to visits.

• Communicate patient summaries and key findings to healthcare providers.

• Obtain any missing or clarified patient information as needed.

• Ensure that documentation complies with Medicare, CMS, and organizational standards.

• Provide telephonic and portal-based care management for patients with complex medical, behavioral health, and socio-economic comorbidities.

• Conduct thorough nursing assessments addressing physical, functional, psychological, social, environmental, and learning needs.

• Develop, implement, and monitor tailored CCM, RPM, RTM, and APCM care plans.

• Complete the creation and annual updates of APCM care plans.

• Utilize motivational interviewing techniques to engage patients and caregivers effectively.

• Monitor patient progress, reassess goals, identify barriers, and modify care plans accordingly.

• Relay patient status and care plan updates to providers and interdisciplinary teams.

• Provide patient education, coaching, and culturally appropriate support.

• Advocate for patients while assisting with problem-solving and escalation when necessary.

• Identify and close gaps in preventive care, laboratory tests, medications, and follow-up care.

• Coordinate orders, referrals, follow-up actions, and care across various services and providers.

• Monitor service delivery to ensure appropriateness, continuity, and quality.

• Maintain accurate, timely, and confidential patient records.

• Utilize CT360, RXNT, Zoom, EHR systems, and telehealth platforms efficiently.

• Support clinical quality, patient engagement, and satisfaction outcomes.

• Adhere to HIPAA, CMS, and organizational compliance standards diligently.

• Engage in professional development and ongoing training opportunities.

• Make independent decisions, prioritize tasks, multitask effectively, and perform other assigned duties.

⛳️ Requirements

• Active, unrestricted Registered Nurse (RN) license in a compact state.

• Willingness to obtain additional state licenses upon hire.

• A minimum of 3 years of clinical nursing experience, including bedside, Primary Care, Med/Surge, or Home Health experience.

• Experience in providing care within a telehealth or virtual care environment.

• Prior remote work experience.

• Familiarity with CCM, RPM, telehealth or virtual care coordination, primary care, or care management.

• Proficiency in using EHR systems and telehealth platforms.

• Strong clinical assessment and care coordination skills.

• Excellent verbal and written communication abilities.

• High level of organization, attention to detail, and time management skills.

• Capability to work independently in a remote setting.

• Commitment to providing patient-centered, culturally competent care.

• Dedicated and private home workspace is essential.

• Employees must perform all work physically within the United States; international work is not permitted during scheduled work hours.

• Must use a Windows or Apple macOS computer only; Chromebooks, Linux machines, or smartphones are not acceptable.

• Minimum requirements include Windows 10 or macOS 14 Sonoma.

• Must have an Intel Core i5 or AMD-equivalent processor on Windows, or Apple Silicon on Mac.

• 16 GB RAM is required.

• Wired headphones without built-in microphones must be used.

• Internet speed must be at least 100 Mbps download and 50 Mbps upload.

• An Ethernet cable must connect the computer directly to the router.

• Google Chrome with Amazon Workspaces is necessary.

• A webcam is required for video calls.

• Preferred: Experience with Medicare Annual Wellness Visits, CMS documentation and preventive care knowledge, case management or gerontological nursing certification, and familiarity with multiple virtual care programs and platforms.

🏝️ Benefits

• Opportunity to obtain additional state licenses upon hire at company expense.

• Access to professional development and ongoing training programs.

• Remote work from a home office.

• Equal opportunity and inclusive work environment.