Chronic Care Management (CCM) Nurse, RN

Job Description

Location: Remote (US-based)

We are hiring for a Chronic Care Management (CCM) Nurse, RN with a Medicare care management organization located in the US. This position is a full-time, direct hire opportunity.

This position is ideal for an RN who enjoys building long-term relationships with patients and making a real difference in managing complex, ongoing health needs.

Responsibilities:

• Provide monthly telephonic care management services to a panel of patients enrolled in the CCM program
• Conduct comprehensive health assessments and develop individualized care plans addressing chronic conditions such as diabetes, heart failure, COPD, and hypertension
• Coordinate care across primary care, specialists, pharmacy, and community resources to address gaps in care
• Monitor patient health status, medication adherence, and self-management progress between visits
• Facilitate timely follow-up after hospital discharge, ED visits, and specialist appointments
• Educate patients on disease management, medication management, and healthy lifestyle behaviors
• Document all CCM interactions accurately to meet CMS billing and compliance requirements
• Identify and address social determinants of health barriers including transportation, housing, and food insecurity
• Collaborate with the care team on escalations, urgent clinical concerns, and transitions of care
• Meet monthly CCM minute requirements and maintain accurate time-tracking records
• Support patient enrollment in the CCM program and obtain required patient consent

Qualifications:

• Active Registered Nurse (RN) license required; compact license preferred
• Associate or Bachelor’s degree in Nursing required
• 2 or more years of clinical nursing experience; chronic disease management or care coordination experience preferred
• Knowledge of CMS Chronic Care Management billing requirements preferred
• Strong telephonic communication, patient education, and documentation skills
• Comfortable working independently in a remote, self-directed environment

Schedule:

• Full-time, Monday through Friday, standard business hours
• 100% remote, must have reliable internet and a quiet, HIPAA-compliant workspace
• Flexible scheduling to accommodate patient availability during business hours

Salary Range: This position offers a competitive salary of $55,000 – $72,000 annually based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.