RN/LPN Chronic Care Manager - Remote

Are you passionate about delivering high-quality patient care and ensuring positive outcomes for individuals with chronic conditions? Do you excel in coordinating care to eliminate gaps and prevent readmissions? If so, we have an exciting opportunity for you to make a difference as a Chronic Care Manager!

As a Chronic Care Manager, you will play a vital role in providing telephonic outreach and patient care coordination tailored to the unique needs of each individual. Collaborating closely with patients' medical providers, you will uphold the highest standards of care in managing qualifying patients with chronic conditions within our Chronic Care Management model.

Key Responsibilities:

• Reach out to eligible patients, offering comprehensive education about our chronic care management program and clarifying any associated cost-sharing components.
• Secure verbal or written consent from enrolled patients, ensuring their understanding and commitment to the program.
• Conduct regular follow-up calls with enrolled patients, meticulously documenting interactions and tracking progress.
• Work collaboratively with the care team to develop personalized care plans for each patient, ensuring holistic and effective management of chronic conditions.
• Facilitate seamless care transitions following ER visits, hospitalizations, or SNF admissions, proactively preventing unnecessary readmissions.
• Foster ongoing communication between patients and other members of the care team, promoting continuity and consistency in care delivery.
• Promptly exchange or request continuity of care documents with relevant practitioners to ensure comprehensive and coordinated care.
• Support patients through the offboarding process if they choose to opt out of the program, ensuring a smooth transition and continuity of care.

Qualifications: To thrive in this role, you will need:

• Availability to work at least 20 hours per week, conducting patient calls and documenting interactions on your computer.
• A dedicated home office or HIPAA-compliant workspace that ensures complete privacy and security of patient health information.
• Access to high-speed internet and a computer less than 3 years old (Chromebooks or MAC PCs not supported).
• An active Arizona RN or LPN license
• Preferred certification in case management (ACM or CCM).
• Strong leadership qualities

Education and Experience:

• A minimum of 5 years of nursing experience, demonstrating a deep understanding of patient care principles and practices.
• Ideally, at least 1 year of experience in hospital or skilled facility case management, showcasing your ability to coordinate complex care scenarios.
• Familiarity with Chronic Care Management or care coordination concepts is highly desired, reflecting your commitment to delivering patient-centered care.