Chronic Care Management Nurse or LPN

About Hoskinson Health & Wellness

Hoskinson Health & Wellness Clinic is a patient-centered healthcare organization proudly serving Gillette and the surrounding community. Our mission is simple: to provide high-quality, compassionate care that helps our patients feel heard, supported, and empowered in their health journey.

We believe healthcare works best when it’s proactive, coordinated, and personal. Through programs like Chronic Care Management (CCM), we focus on improving outcomes for patients living with multiple chronic conditions by providing ongoing support, education, and care coordination.

Just as we care deeply about our patients, we care about our team. We value collaboration, integrity, accountability, and continuous improvement. We are committed to building a supportive workplace where nurses are empowered to practice at the top of their license and make a measurable impact on patient health.

If you’re passionate about population health, preventive care, and meaningful patient relationships, Hoskinson Health & Wellness is a place where your work truly matters.

Why Work at Hoskinson Health & Wellness?

At Hoskinson Health & Wellness, we believe supporting our clinical team is essential to delivering exceptional patient care. We offer a competitive compensation package and comprehensive benefits designed to promote work-life balance, professional development, and long-term career stability.

You’ll join a collaborative care team focused on improving patient outcomes, reducing hospitalizations, and enhancing quality of life for individuals managing chronic conditions.

When you join Hoskinson Health & Wellness, you’re not just accepting a job—you’re becoming part of a mission-driven organization committed to proactive, patient-centered healthcare.

About the Role

The Chronic Care Management (CCM) Nurse (LPN or RN) coordinates and manages care for patients with multiple chronic conditions in accordance with CMS Chronic Care Management guidelines. This role focuses on proactive patient outreach, individualized care planning, medication reconciliation, and interdisciplinary coordination to improve patient outcomes and reduce preventable hospitalizations.

This position is ideal for a nurse who thrives in care coordination, patient education, and telehealth-driven environments.

Key Responsibilities

Patient Identification & Enrollment

• Identify and enroll eligible patients into the CCM program per CMS guidelines

• Educate patients about program benefits and obtain required consents

Care Planning & Coordination

• Develop, implement, and regularly update individualized electronic care plans

• Conduct routine telephonic or electronic follow-up with enrolled patients

• Coordinate care transitions following hospital or emergency department discharge

• Facilitate referrals to specialists, behavioral health providers, and community resources

• Communicate changes in patient condition to primary care providers

Medication & Chronic Disease Management

• Perform medication reconciliation and adherence monitoring

• Provide patient education related to chronic disease management (e.g., diabetes, COPD, CHF, hypertension)

• Use motivational interviewing techniques to encourage self-management

Documentation & Compliance

• Document all patient encounters in compliance with CMS CCM billing requirements

• Track CCM time accurately to support appropriate billing

• Maintain strict HIPAA compliance and confidentiality

• Assist in monitoring quality metrics and support population health initiatives

Supervisory Responsibilities

• This role does not have direct supervisory responsibility

• May provide clinical guidance to Medical Assistants or Care Coordinators

• May assist in training new CCM staff

• Participates in interdisciplinary care coordination meetings and team huddles

Qualifications

Education & Licensure

LPN Requirements

• Graduate of an accredited School of Practical Nursing

• Current, unrestricted Wyoming LPN license

• Current BLS certification

RN Requirements

• Graduate of an accredited School of Nursing (ADN required; BSN preferred)

• Current, unrestricted Wyoming RN license

• Current BLS certification

Experience

• Minimum of 1–2 years of clinical nursing experience required

• Experience in primary care, internal medicine, geriatrics, family practice, or care coordination preferred

• Experience with EHR systems required

• Familiarity with Medicare CCM billing guidelines preferred

Skills & Competencies

• Strong care coordination and organizational skills

• Knowledge of chronic disease management principles

• Understanding of CMS Chronic Care Management billing regulations

• Excellent communication and motivational interviewing skills

• Ability to work independently in a telehealth-driven environment

• Strong documentation and time-management skills

• Proficiency in EHR systems

• Knowledge of HIPAA and patient privacy regulations

• Ability to manage multiple patients and time-sensitive responsibilities

Work Environment & Physical Requirements

• Primarily clinic-based and telephonic care coordination environment

• Extended periods of sitting, standing, and computer use

• Light physical work with occasional lifting up to 10 pounds

• Exposure to clinical environments as needed

Equal Opportunity Employer

Hoskinson Health & Wellness Clinic is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. Reasonable accommodations are available upon request during the application or interview process.