Homeoffice Chronic Care Management (CCM) Nurse bei Quorum Health

Chronic Care Management (CCM) Nurse
Full-Time Remote Position

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.

Duties and Responsibilities

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. 

Knowledge, Skills and Abilities:  

• Excellent interpersonal and communication skills, with the ability to engage patients and collaborate with multidisciplinary teams.
• Strong organizational skills and attention to detail for managing multiple patients' care plans.
• Proficiency in using electronic health records (EHR) and care management software.
• Ability to work independently, manage time effectively, and maintain productivity in a remote setting.

Work Experience, Education and Certifications: 

• Minimum of 2 years of nursing experience, preferably in chronic disease management, care coordination, case management, or population health.
• 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.
• Associate's or Bachelor's degree in nursing or a related field from an accredited program.

This job description is intended to describe the general nature and level of work being performed. It is not an exhaustive list of all responsibilities, duties and skills required to perform this job. This may be modified at the sole discretion of the company. 

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.