chronic care nurse

Cahaba Medical Care Foundation

<div><div><b>Chronic Care Management Nurse/RN</b></div><div></div><div><i><br>
Reports to </i><b><i>Chief Quality Officer</i></b></div><div><b><br>
 Cahaba Medical Care Foundation</b></div><p><b>
 Supervised by: </b>Chief Quality Officer</p><h3 class="jobSectionHeader">
Position Overview:</h3><p>
The Chronic Care Management Nurse plays a pivotal role in providing personalized care for patients with chronic conditions, including but not limited to diabetes, hypertension, asthma, COPD, heart disease, and other long-term illnesses. This role involves monitoring patients' health status, educating them on their conditions, ensuring adherence to treatment plans, and promoting proactive measures to prevent complications. The Chronic Care Management Nurse collaborates closely with physicians, care teams, and patients to deliver high-quality care in a clinic setting.</p><h3 class="jobSectionHeader">
Working Environment:</h3><ul><li><p>
Clinic Hours: Monday to Friday, 8:00 AM &ndash; 5:00 PM (with occasional extended hours depending on patient needs).</p></li><li><div>
Environment: Fast-paced, team-oriented, and patient-focused clinic setting.</div></li><li><p>
Physical Demands: Standing, walking, and sitting for extended periods. Occasional lifting of patients or equipment may be required.</p></li></ul><h3 class="jobSectionHeader">
Key Responsibilities:</h3><h4 class="jobSectionHeader">
Patient Care &amp; Management:</h4><ul><li><p>
Chronic Disease Management:</p><ul><li><div><br>
Monitor and assess the health status of patients with chronic conditions, including vital signs, lab results, medications, and treatment adherence.</div></li><li><div>
Provide ongoing education and support to patients on managing their chronic conditions and improving health outcomes.</div></li><li><div>
Collaborate with physicians and other healthcare providers to develop and implement personalized care plans based on patient needs.</div></li><li><div>
Offer routine assessments for patients in both in-person and remote settings, such as phone calls or telehealth visits.</div></li></ul></li><li><div>
Medication Management:</div><ul><li><div><br>
Educate patients on the proper use of prescribed medications and monitor for adherence, side effects, and potential drug interactions.</div></li><li><div>
Coordinate medication refills and communicate with pharmacies/providers as necessary.</div></li><li><div>
Assist in adjusting medication regimens as ordered by the physician, in accordance with established protocols.</div></li></ul></li><li><div>
Care Coordination:</div><ul><li><div><br>
Act as a point of contact for patients with chronic conditions, ensuring that all aspects of care are coordinated, including referrals, tests, and specialist visits.</div></li><li><div>
Communicate and follow up with patients to ensure continuity of care and address any issues or concerns promptly.</div></li><li><p>
Monitor patients' progress and identify early signs of complications or deterioration in their condition.</p></li></ul></li></ul><h4 class="jobSectionHeader">
Education &amp; Support:</h4><ul><li><p>
Patient Education:</p><ul><li><div><br>
Provide education on managing chronic diseases, including self-management skills, lifestyle changes, diet, exercise, and coping strategies.</div></li><li><div>
Educate patients and their families on the importance of preventative care, such as routine screenings, immunizations, and other health-related behaviors.</div></li><li><div>
Use self management methods to ensure patients understand their treatment plans and health goals.</div></li></ul></li><li><div>
Health Promotion:</div><ul><li><div><br>
Help patients set realistic, measurable goals to improve their health and quality of life.</div></li><li><div>
Guide patients through disease-specific management strategies, including symptom monitoring, tracking triggers, and recognizing warning signs.</div></li><li><p>
Empower patients to take ownership of their health and become active participants in their care plans.</p></li></ul></li></ul><h4 class="jobSectionHeader">
Documentation &amp; Reporting:</h4><ul><li><p>
Patient Records:</p><ul><li><div><br>
Maintain accurate and up-to-date patient records in compliance with clinic policies and relevant regulations (e.g., HIPAA).</div></li><li><div>
Document patient assessments, care plans, interventions, progress notes, and any changes in condition or treatment in the electronic health record (EHR).</div></li><li><p>
Complete required reports related to chronic care management programs, including billing and outcome documentation.</p></li></ul></li></ul><h4 class="jobSectionHeader"><br>
Quality Improvement:</h4><ul><li><p>
Outcomes Monitoring:</p><ul><li><div><br>
Track and report on the effectiveness of chronic care management services, identifying areas for improvement in care delivery.</div></li><li><div>
Participate in quality improvement initiatives aimed at improving patient outcomes and enhancing the overall care process.</div></li><li><p>
Support the clinic&rsquo;s efforts to meet accreditation standards, quality measures, and performance benchmarks for chronic care management.</p></li></ul></li></ul><h3 class="jobSectionHeader">
Skills and Qualifications:</h3><ul><li><p>
Education and Certification:</p><ul><li><div><br>
Registered Nurse (RN) or Licensed Practical Nurse (LPN)with an active state license.</div></li><li><div>
BLS (Basic Life Support) certification</div></li></ul></li><li><div>
Experience:</div><ul><li><div><br>
Minimum of 2-3 years of nursing experience, with a focus on chronic disease management, geriatrics, or related areas.</div></li><li><div>
Experience working in a clinic or outpatient setting preferred.</div></li><li><div>
Knowledge and experience in patient education, health promotion, and care coordination.</div></li></ul></li><li><div>
Technical Skills:</div><ul><li><div><br>
Proficiency with Electronic Health Records (EHR) systems.</div></li><li><div>
Basic knowledge of chronic care management programs and healthcare regulations.</div></li><li><div>
Familiarity with telemedicine platforms and remote patient monitoring is a plus.</div></li></ul></li><li><div>
Interpersonal Skills:</div><ul><li><div><br>
Excellent communication skills, both verbal and written, to effectively interact with patients, families, and healthcare professionals.</div></li><li><div>
Ability to work collaboratively within a multidisciplinary team.</div></li><li><div>
Strong critical thinking and problem-solving skills, with the ability to assess complex situations and make sound clinical decisions.</div></li></ul></li><li><div>
Personal Attributes:</div><ul><li><div><br>
Empathy and compassion for patients with chronic conditions.</div></li><li><div>
Strong organizational skills and attention to detail.</div></li><li><div>
Ability to manage a high volume of patients and prioritize care effectively.</div></li></ul></li></ul><h3 class="jobSectionHeader">
Additional Information:</h3><p>
The Chronic Care Management Nurse is a critical member of our care team, dedicated to improving the health and quality of life of patients with chronic conditions. This role provides an opportunity to make a meaningful difference in the lives of patients, empowering them to manage their health and prevent complications associated with chronic diseases.</p></div>

Chronic Care Management Nurse

Vitality Home Health Care

<div><div><div><b>Benefits:</b></div>
<ul><li>Competitive salary</li>
<li>Flexible schedule</li>
<li>Opportunity for advancement</li>
</ul></div><div><div>About Us:</div>
<div>We are a growing home care agency expanding our <b>Chronic Care Management (CCM) and care coordination services</b> to better support patients with multiple chronic conditions. Our mission is to improve outcomes, reduce hospitalizations, and provide proactive, patient-centered care in collaboration with caregivers, families, and providers.<br>
</div><div>Position Summary:</div>
<div>We are seeking a <b>Nurse Practitioner (NP)</b> to lead and support our <b>Chronic Care Management program</b>. This role focuses on care coordination, clinical oversight, patient education, and interdisciplinary collaboration for patients with two or more chronic conditions. The ideal candidate is organized, compassionate, and experienced in managing complex patients outside of traditional office visits.<br>
</div><div>Key Responsibilities<br>
</div>Conduct comprehensive in person CCM assessments and ongoing monthly care management. Monthly management is done remotely.<br>
<ul><li>
</li>Develop, implement, and update individualized care plans<br>
<li>
</li>Monitor chronic conditions (e.g., CHF, COPD, diabetes, hypertension, dementia)<br>
<li>
</li>Coordinate care with physicians, specialists, caregivers, and community resources<br>
<li>
</li>Provide patient and family education and support via phone or telehealth<br>
<li>
</li>Identify gaps in care and intervene proactively to prevent hospitalizations<br>
<li>
</li>Document CCM activities accurately in accordance with Medicare guidelines<br>
<li>
</li>Support compliance with CMS CCM requirements and quality measures<br>
<li>
</li>Collaborate with agency leadership to grow and enhance the care management program<br>
<li>
</li></ul><div>Qualifications<br>
</div>Active Nurse Practitioner license (state-specific)<br>
<ul><li>
</li>National NP certification (AANP or ANCC)<br>
<li>
</li>Minimum 2 years of clinical experience (primary care, geriatrics, home care, or care management preferred)<br>
<li>
</li>Experience with chronic disease management and care coordination<br>
<li>
</li>Familiarity with Medicare CCM services and documentation requirements (preferred)<br>
<li>
</li>Strong communication, organization, and time-management skills<br>
<li>
</li>Comfortable working independently in a remote or hybrid environment<br>
<li>
</li>EMR experience required<br>
<li>
</li></ul><div>What We Offer<br>
</div>Competitive compensation<br>
<ul><li>
</li>Flexible schedule (ideal for work-life balance)<br>
<li>
</li>Opportunity to help build and shape a growing CCM program<br>
<li>
</li>Collaborative, mission-driven work environment<br>
<li>
</li>Supportive leadership and administrative support<br>
<li>
</li>
</ul></div><p>Flexible work from home options available.</p></div>

Nurse Practitioner Chronic Care Management

Vitability Health

<div><h2 class="jobSectionHeader"><b>Chronic Care Manager (RN)</b></h2>
<p><b>
Vitability Health of New Jersey</b><br>
<i>Remote Position</i></p>
<h3 class="jobSectionHeader"><b>
Our Mission</b></h3>
<p>
At Vitability Health of New Jersey, we believe great care goes beyond checklists and charts&mdash;it&rsquo;s about relationships, trust, and walking alongside patients as they navigate life with chronic conditions. Our mission is to improve quality of life through thoughtful, personalized care that meets patients where they are and supports them every step of the way.</p>
<h3 class="jobSectionHeader"><b>
About the Role</b></h3>
<p>
We are looking for a compassionate and experienced <b>Chronic Care Manager (RN)</b> who is passionate about caring for patients over the long term. In this role, you will build meaningful relationships with patients, help them better understand and manage their health, and serve as a steady, trusted presence in their care journey.</p>
<p>
This position is ideal for a nurse who values connection, collaboration, and purpose&mdash;and who enjoys using clinical expertise to make a real difference, all while working remotely.</p>
<h3 class="jobSectionHeader"><b>
What You&rsquo;ll Do</b></h3>
<ul>
<li><p>Provide ongoing <b>chronic care management</b> to a caseload of patients living with multiple chronic conditions</p>
</li>
<li><p>Develop and maintain <b>personalized care plans</b> that reflect each patient&rsquo;s goals, challenges, and needs</p>
</li>
<li><p>Conduct comprehensive assessments to understand medical, social, and lifestyle factors affecting health</p>
</li>
<li><p>Monitor patient progress, identify changes early, and adjust care plans to support better outcomes</p>
</li>
<li><p>Educate and encourage patients and their families on disease management, medications, and healthy lifestyle choices</p>
</li>
<li><p>Use <b>telehealth and remote monitoring</b> to stay connected with patients between visits</p>
</li>
<li><p>Partner with Care Navigators (social workers) by delegating tasks and supporting their work to ensure seamless, high-quality care</p>
</li>
<li><p>Collaborate with providers and interdisciplinary team members to promote continuity and alignment across care</p>
</li>
<li><p>Support medication reconciliation and help patients feel confident in understanding their treatment plans</p>
</li>
<li><p>Assist with coordinating appointments, tests, and follow-ups to reduce barriers to care</p>
</li>
<li><p>Help patients access community resources and support services that enhance overall well-being</p>
</li>
<li><p>Work proactively to reduce hospital readmissions and emergency department visits through consistent engagement</p>
</li>
<li><p>Maintain clear, timely, and compliant documentation in the EHR in accordance with <b>HIPAA</b> and CMS guidelines</p>
</li>
<li><p>Track patient outcomes and quality measures to help strengthen and grow our care management programs</p>
</li>
<li><p>Stay informed on best practices and evolving standards in chronic care management</p>
</li>
</ul><h3 class="jobSectionHeader"><b>What We&rsquo;re Looking For</b></h3>
<ul>
<li><p>Active <b>Registered Nurse (RN)</b> license in New Jersey <b>or</b> a valid Compact RN License</p>
</li>
<li><p>Experience in <b>Chronic Care Management (CCM)</b></p>
</li>
<li><p>Required <b>acute care nursing experience</b></p>
</li>
<li><p>A caring, patient-centered approach with a genuine desire to support patients over time</p>
</li>
<li><p>Strong communication and organizational skills</p>
</li>
<li><p>Ability to lead and collaborate with care coordinators in a supportive, team-oriented way</p>
</li>
<li><p>Comfort using EHR systems, telehealth platforms, and remote patient monitoring tools</p>
</li>
<li><p>Ability to work independently while staying connected to a collaborative care team</p>
<p>
Love this direction. This is exactly where you win great nurses back to meaningful work.</p>
<p></p>
<h3 class="jobSectionHeader"><b>Why Vitability Health</b></h3>
<p>
At Vitability Health, we care deeply about our patients&mdash;and just as deeply about the people who care for them. We&rsquo;ve intentionally built a work environment that values balance, trust, and sustainability, so our nurses can do their best work without sacrificing their well-being.</p>
<p>
Here&rsquo;s what you can expect:</p>
<ul>
<li><p><b>Fully Remote Work</b><br>
Work from the comfort of your home&mdash;no commute, no traffic, and no unnecessary stress. We believe great care can happen anywhere.</p>
</li>
<li><p><b>True Work/Life Balance</b><br>
This role follows a <b>strict 9:00&ndash;5:00 schedule</b> with <b>no nights, weekends, and very limited on-call expectations</b>. When your workday ends, your time is yours.</p>
</li>
<li><p><b>Paid Holidays Off</b><br>
We observe major holidays so you can rest, recharge, and spend meaningful time with family and loved ones.</p>
</li>
<li><p><b>Paid Time Off (PTO)</b><br>
PTO is available because rest isn&rsquo;t a luxury&mdash;it&rsquo;s essential to providing great care.</p>
</li>
<li><p><b>Monthly Work Flexibility</b><br>
We understand life happens. Our team is supported with built-in flexibility each month to attend appointments, family needs, or personal responsibilities without guilt.</p>
</li>
<li><p><b>Purpose-Driven Work</b><br>
Build long-term relationships with patients and see the impact of your care over time&mdash;no rushed encounters, no revolving doors.</p>
</li>
<li><p><b>Supportive, Team-Oriented Culture</b><br>
You&rsquo;ll be part of a collaborative care team that values communication, respect, and shared success.</p>
</li>
<li><p><b>A Sustainable Nursing Career</b><br>
This role is designed for nurses who want to continue making a difference&mdash;without burnout, physical strain, or emotional exhaustion.</p></li></ul></li></ul></div>

Remote Registered Nurse Chronic Care Management

Ohio Valley Pain Institute

<p>We are looking for a Nurse Practitioner or Physician Assistant to diagnose and treat health conditions, as well as promote good health practices. As a Nurse Practitioner/Physician Assistant, you&rsquo;ll be our go-to person for ensuring the best patient care possible. The job description includes conducting physical examinations, interpreting lab tests and overseeing patients&rsquo; health. You&rsquo;ll be both a health practitioner and an educator, supporting disease prevention practices and helping people lead healthy lives. As a Nurse Practitioner/Physician Assistant, you&rsquo;ll have to work closely with other healthcare professionals, so you should have a team spirit and a positive attitude. Patience, problem-solving skills and communication ability are important.</p><p><b>Responsibilities</b></p><ul><li>Examine patients and their medical records</li><li>Order and study diagnostic tests (blood tests, X-rays etc.)</li><li>Diagnose health conditions and illnesses</li><li>Propose treatments for chronic and infectious diseases</li><li>Prescribe medications</li><li>Maintain accurate records and schedules</li><li>Inform patients about their health conditions and prescribed medications</li><li>Educate patients and their family members on diseases, epidemics and prevention</li><li>Oversee patients&rsquo; overall health</li><li>Promote good health practices</li><li>Advance professional knowledge and conduct research</li></ul><p><b>Skills</b></p><ul><li>Proven experience as Nurse Practitioner in a clinic, hospital, ER or other setting</li><li>Expertise in primary care, acute care and chronic care practices</li><li>Knowledge of health and patient care regulations</li><li>Excellent communication skills</li><li>Strong ethics</li><li>Team spirit with a positive attitude</li><li>Patience and cool-headedness</li><li>Willingness to continue gaining knowledge and clinical experience</li><li>Valid nurse practitioner license or physician assistant certification</li></ul><p>Job Types: Full-time, Part-time</p><p>Benefits:</p><ul><li>401(k)</li><li>401(k) matching</li><li>Paid time off</li></ul><p>Ability to Commute:</p><ul><li>Louisville, KY 40217 (Required)</li></ul><p>Ability to Relocate:</p><ul><li>Louisville, KY 40217: Relocate before starting work (Required)</li></ul><p>Work Location: In person</p>

Physician Assistant-Certified or Advanced Registered Nurse Practitioner

Cadence Solutions

<div><div><p>In the U.S., 60% of adults &ndash; more than 133 million people &ndash; live with at least one chronic condition. These patients need frequent, proactive support to stay healthy, yet our care system isn't built for that level of attention. With rising clinician shortages, strained infrastructure, and reactive care models, patients too often end up in the ER or the hospital when those outcomes could have been prevented.</p>
<p>
At Cadence, we're building a better system. Our mission is to deliver proactive care to one million seniors by 2030. Our technology and clinical care team extend the reach of primary care providers and support patients every day at home. In partnership with leading health systems, Cadence consistently monitors tens of thousands of patients to improve outcomes, reduce costs, and help patients live longer, healthier lives.</p></div><p>
Cadence Health is seeking a skilled Licensed Practical/Vocational Nurse (LPN/LVN) to join our dynamic team. The LPN/LVN will play a crucial role in our mission by providing support to patients with chronic conditions. This position is remote, operating within the framework of a rapidly evolving healthcare technology startup environment.</p>
<p><b>
Schedule Requirements:</b></p>
<ul>
<li><div>Weekend coverage required every Saturday and Sunday</div>
</li><li><div>Available shift options (all times Eastern Time):</div>
<div><ul><li>9:00 AM to 9:00 PM</li>
<li>10:00 AM to 10:00 PM</li>
<li>11:00 AM to 11:00 PM</li>
</ul><b>OR</b>
<ul><li>Saturday, Sunday and Monday: 2:00 PM to 11:00 PM</li>
</ul>
</div></li></ul><p><b>What you'll do:</b></p>
<ul>
<li>Conduct remote monitoring of patient vital signs, symptoms, and other health indicators.</li>
<li>Identify patients requiring immediate clinical intervention based on monitored data and established criteria.</li>
<li>Follow up promptly with patients showing abnormal readings to gather additional clinical information.</li>
<li>Collaborate closely with Cadence Nurses and Nurse Practitioners to ensure coordinated care management.</li>
<li>Maintain accurate clinical documentation and contribute to the development of comprehensive care summaries for healthcare providers.</li><br>
</ul>
<p><b>What you need:</b></p>
<ul>
<li>Licensed Practical/Vocational Nurse(LPN/LVN) with compact licensure</li>
<li>Minimum 5 years of experience as an LPN/LVN</li>
<li>Minimum 3 years of experience in a cardiology setting.</li>
<li>Strong ability to think critically and adapt swiftly to a dynamic work environment.</li>
<li>Experience working in remote patient monitoring or telemedicine settings is highly desirable.</li>
<li>Proficient in reading, writing, and communicating professionally and effectively within clinical documentation and with patients.</li>
<li>Familiarity with healthcare technology and a startup environment is a plus.</li>
</ul>
<p>The anticipated compensation range for this role is <b>$27</b><b> to $33 per hour, </b>which is based on role scope, level, and location. This position is remote and based in the United States. Actual compensation will be determined based on factors including experience, skills, internal equity, and applicable law.</p><div><p><b>
Who we are</b></p>
<p>
Cadence Health was built around a simple promise: patients always come first. Our technology-enabled remote care model pairs continuous health insights with a highly skilled clinical Care Team, empowering seniors to stay healthier, avoid complications, and live more independent, fulfilling lives, all without the limits of a traditional office visit.</p>
<p><b>
Your expertise is the heart of our system.</b><br>
Nurse practitioners, registered nurses, medical assistants, patient-success coordinators, and other frontline clinicians are the face and beating heart of Cadence. You'll bring warmth, clinical precision, and the empathy that turns a virtual touchpoint into a human connection. Every chat, phone call, and care plan you deliver shapes how patients experience &quot;what healthcare should be.&quot;</p>
<p><b>
A modern toolkit to practice top-of-license care</b><br>
We've replaced reactive visits with real-time data, intelligent workflows, and seamless collaboration tools. That means you can spend less time on busywork and more time practicing at the top of your license, coaching patients, spotting risks early, and coordinating with physicians to keep care proactive and personal.</p>
<p><b>
Thriving in a fast-moving, mission-driven culture.</b><br>
Change excites us. Innovation fuels us. If you're energized by technology, eager to re-imagine care delivery, and motivated to improve outcomes for both patients and the providers who serve them, you'll feel at home here. We invest in continuous learning, clinical mentorship, and transparent growth paths so you can advance your skills while making a measurable impact every day.</p>
<p><b>
Join us in redefining healthy aging.</b><br>
If you're passionate about compassionate care and ready to transform how seniors across the country manage chronic conditions, recover after hospitalization, and age with confidence, let's talk. Together, we'll build a future where exceptional care is consistent, connected, and just a call away.</p>
<p><b>
What You'll Get:</b></p>
<p><i>
Cadence full-time employees are eligible for the benefits described below. Part-time employees may qualify for benefits mandated by state or local law.</i></p>
<p>
Cadence recognizes the unique needs of its diverse, distributed workforce and seeks to provide an inclusive work environment for its world-class clinicians and technologists.</p>
<ul>
<li>Company culture all about impact, shared growth mindset, empowerment, and integrity</li>
<li>An opportunity to help improve the quality of life of millions of Americans</li>
<li>Unique chance to support the development of an amazing product; Cadence's in-house clinicians are our super users and beta testers</li>
<li>Competitive salaries and quarterly incentives</li>
<li>Medical, dental, and vision insurance</li>
<li>Competitive PTO</li>
<li>401K and 401K match</li>
<li>National and local discounts powered by TriNet</li>
<li>Onboarding stipend for remote equipment and home office setup</li>
<li>Paid Parental Leave</li>
<li>Charitable Donation Match program</li>
</ul>
<div><i>We are committed to equal opportunity and fairness regardless of race, color, religion, sex, gender identity, sexual orientation, nation of origin, ancestry, age, physical or mental disability, country of citizenship, medical condition, marital or domestic partner status, family status, family care status, military or veteran status or any other basis protected by local, state or federal laws. </i><i>Candidates must be willing to comply with all pre-employment drug screening requirements and, where applicable, comply with additional drug screening requirements as a condition of continued employment in accordance with company policy and applicable law.</i><br>
<br>
<ul><li><i>A notice to Cadence applicants: Our Talent team only directs candidates to apply through our official careers page at </i><i>https://www.cadence.care/our-team</i><i>.</i><i> </i><i>Cadence will never refer you to external websites, ask for payment or personal information, or conduct interviews via messaging apps. We receive all applications through our website and anyone suggesting otherwise is not with Cadence.</i></li></ul></div></div></div>

Part-Time Weekend Licensed Practical Nurse (Alerts)

Fair Hill Community Physicians

<p><b>This role is predominately remote, during the first 60 days there is onsite training. </b></p><p><b>One day in the office a week!</b></p><p><b>Job Summary</b></p><p><b>The Care Coordination Nurse (CCN) must be able to speak Spanish and English fluently</b>. The CCN plays a critical role in delivering high-quality chronic care management (CCM) services to patients with complex medical conditions. The nurse will support patients through monthly outreach, care planning, and health coaching to improve long-term health outcomes and reduce unnecessary hospital utilization. This role requires strong clinical judgment, attention to detail, and a passion for patient-centered care.</p><p>&middot; Licensure: Active LPN license in Pennsylvania required; <b>RN strongly preferred.</b></p><p><b>Skills:</b></p><ul><li>Strong communication and interpersonal skills</li><li>Proficient in navigating EHRs and digital communication tools</li><li>Ability to work independently and manage a patient panel</li></ul><p><b>Experience </b></p><ul><li>Experience: Minimum of 2 years of nursing experience in a clinical, community health, or care coordination role.</li><li>Experience in primary care, family medicine, or community health settings (Preferred)</li><li>Experience with chronic care populations preferred</li><li>Experience in delivering care coordination in a remote position to set up FHCP for transitions of care, ER diversion/follow up, and appointment scheduling.</li></ul><p>&middot; Patient-Centered Care</p><p>&middot; Health Education &amp; Coaching</p><p>&middot; Clinical Documentation</p><p>&middot; Interdisciplinary Collaboration</p><p><b>Teamwork</b></p><p>How this is demonstrated in this role:</p><ul><li>Collaborates closely with providers, care teams, and FairHill Health staff to ensure coordinated patient care.</li><li>Actively participates in case reviews and team huddles to share insights and improve patient outcomes.</li><li>Supports colleagues by sharing best practices and helping to cover caseloads as needed.</li></ul><p><b>Adaptability</b></p><p>How this is demonstrated in this role:</p><ul><li>Adjusts care plans in real time based on evolving patient needs, health status, or life circumstances.</li><li>Navigates multiple systems and technologies (EHRs, telehealth platforms, reporting tools) with flexibility.</li><li>Embraces changes in workflows or regulatory guidelines while maintaining high-quality service.</li></ul><p><b>Communication</b></p><p>How this is demonstrated in this role:</p><ul><li>Maintains clear, compassionate, and culturally sensitive communication with patients and families.</li><li>Effectively relays patient updates and concerns to providers and clinical supervisors in a timely manner.</li><li>Uses written documentation and verbal updates to ensure continuity of care and accurate records.</li></ul><p><b>Accountability</b></p><p>How this is demonstrated in this role:</p><ul><li>Follows through on outreach, documentation, and follow-ups with consistency and integrity.</li><li>Maintains accurate, timely records in compliance with organizational and CMS guidelines.</li><li>Takes responsibility for meeting performance metrics and proactively addresses barriers to success.</li></ul><p><b>Perform monthly outreach to assigned patients enrolled in the Chronic Care Management (CCM) program.</b></p><ul><li>Demonstrate the ability to deliver large volumes of phone calls and emails support to patients.</li><li>Utilize a person-centered approach to review and update care plans, assess patient health status, and promote engagement in self-management.</li><li>Document all interactions and updates in the electronic health record (EHR) in accordance with CMS and FHCP documentation standards.</li><li>Collaborate with FHCP providers to ensure alignment of patient care plans.</li><li>Address patient questions related to medications, test results, appointments, or clinical instructions; escalate to providers as necessary.</li><li>Monitor and report changes in patient conditions, adherence concerns, or emerging social determinants of health.</li><li>Educate patients on managing chronic conditions, lifestyle modification, and treatment adherence.</li><li>Assist in identifying patients who may benefit from community-based resources or additional clinical support.</li><li>Maintain compliance with HIPAA and all applicable privacy and security protocols.</li></ul><p><b>Physical Requirements, Physical Demands and Work </b></p><p>Environment Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. To request accommodation, contact Human Resources. FHCP is committed to compliance with federal, state, and local laws regarding individuals with disabilities.</p><p><i>Fair Hill Community Physicians is an equal opportunity employer. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected category. encourage candidates from all backgrounds to apply.</i></p><p>Job Type: Full-time</p><p>Pay: From $90,000.00 per year</p><p>Benefits:</p><ul><li>403(b)</li><li>403(b) matching</li><li>Dental insurance</li><li>Disability insurance</li><li>Flexible spending account</li><li>Health insurance</li><li>Life insurance</li><li>Paid sick time</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Language:</p><ul><li>Spanish (Required)</li></ul><p>License/Certification:</p><ul><li>RN License (Required)</li></ul><p>Work Location: Hybrid remote in Philadelphia, PA 19140</p>

RN Care Coordinator-Full time/Bilingual (Spanish) Hybrid (1 day in office per week)

Wellwink Health

<p><b>Job Summary</b></p><p>Independent Contractor (1099) : We are seeking a qualified Per Diem Licensed Nurse Practitioner (NP) with experience in Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) to provide high-quality care to patients with chronic conditions through Telehealth and remote care services<b>. </b></p><p><b>Work Location:</b> Remote &ndash; NY License Only</p><p><b>Compensation</b></p><ul><li><b>Pay Rate:</b> $28.00 &ndash; $35.00 per hour</li><li>Compensation is based on experience, qualifications, and client care needs</li></ul><p><b>Classification &amp; Benefits</b></p><ul><li>Independent Contractor (1099)</li><li>This position does not include health insurance or employee benefits</li><li>The LPN functions independently within their licensed scope of practice</li></ul><p><b>Primary Responsibilities</b></p><ul><li>Coordinate a variety of healthcare programs</li><li>Manage and monitor patients enrolled in CCM and RPM programs.</li><li>Conduct patient assessments and provide clinical oversight via telehealth.</li><li>Review and interpret RPM data and initiate appropriate clinical interventions.</li><li>Develop, review, and update individualized care plans.</li><li>Collaborate with physicians, patients, families</li><li>Support quality improvement initiatives and patient engagement.</li><li>Ensure accurate EHR documentation and compliance with CMS and HIPAA requirements.</li><li>Communicate with patients regarding treatment plans, goals, abnormal readings, and follow-ups.</li><li>Review daily measures and patient analytics</li><li>Oversee a monthly patient roster, ensuring comprehensive care for each patient</li><li>Aiming for a patient engagement rate of 90% or higher</li></ul><p><b>Qualifications</b></p><ul><li>Active Nurse Practitioner license in New York.</li><li>1&ndash;2 years of NP experience in CCM and/or RPM.</li><li>Experience with Telehealth platforms and EHR systems.</li><li>Strong clinical judgment and communication skills.</li><li>Solid problem-solving and organizational skills</li><li>Ability to manage multiple projects or tasks and prioritize appropriately</li><li>Ability to work in fast-paced situations and make sound decisions quickly</li><li>Excellent interpersonal skills and high level of compassion</li><li>Comfortable learning and using EHR platforms</li></ul><p>Job Types: Contract, Per diem, Non-tenure</p><p>Pay: $28.00 - $35.00 per hour</p><p>Work Location: Remote</p>

Per Diem Licensed Nurse Practitioner (CCM/RPM)

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