Chronic Care Management Nurse

• Job Title: Registered Nurse (RN) – Chronic Care Management
• Location: Hybrid/Remote
• Job Type: Full-Time
• Reports to: Practice Administrator and Physicians

*Position

Summary

*

We are seeking a dedicated and compassionate Registered Nurse (RN) to join our Chronic Care Management (CCM) team. In this role, you will provide remote or in-person care coordination, education, and clinical support to patients with two or more chronic conditions. Your goal is to help improve patient outcomes, enhance quality of life, reduce hospitalizations, and promote long-term health and wellness.

*Key

Responsibilities

*

• Develop, implement, and update individualized care plans in collaboration with the patient, providers, and interdisciplinary team.
• Conduct regular check-ins with patients (telephonic, video, or in-person) to monitor progress, address concerns, and reinforce care plan adherence.
• Educate patients and caregivers about chronic disease self-management, medication adherence, and lifestyle modifications.
• Monitor clinical status and intervene early to prevent exacerbations and avoid unnecessary ER visits or hospitalizations.
• Collaborate with providers, specialists, and care team members to ensure continuity and coordination of care.
• Document all interactions and care activities according to CMS chronic care management guidelines and organizational policies.
• Track patient metrics and outcomes using electronic health records (EHR) and population health tools.
• Identify and address social determinants of health affecting care access or adherence.
• Ensure compliance with HIPAA, CMS regulations, and organizational protocols.

*

Qualifications

*

Current RN license* in North Carolina Minimum 2 years* of nursing experience, preferably in primary care, care coordination, case management, or chronic disease management.

• Experience with conditions such as diabetes, CHF, COPD, hypertension, CKD, or behavioral health is a plus.
• Strong clinical assessment, communication, and patient engagement skills.
• Proficient in EHR systems and telehealth platforms.
• Knowledge of CMS Chronic Care Management guidelines preferred.
• Ability to work independently and as part of a multidisciplinary team.

Preferred Qualifications

*

• Certified Case Manager (CCM), Chronic Care Professional (CCP), or equivalent credential.

Work Environment

• [Remote or office-based], with scheduled patient outreach hours.
• May require occasional travel to clinics
• Standard business hours with potential flexibility depending on patient needs.

*

Benefits

*

Health insurance, 401(k), PTO, WNC YMCA membership

Job Types: Full-time, Permanent Pay: $65,000.00 - $80,000.00 per year

Benefits

• 401(k) matching
• Flexible schedule
• Health insurance
• Paid time off

Work Location: Hybrid remote in Arden, NC 28704