Chronic Care Management Nurse or LPN

Hoskinson Biotechnology•Gillette, WY

19h

About The Position

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.

Requirements

Graduate of an accredited School of Practical Nursing
Current, unrestricted Wyoming LPN license
Current BLS certification
Graduate of an accredited School of Nursing (ADN required; BSN preferred)
Current, unrestricted Wyoming RN license
Current BLS certification
Minimum of 1–2 years of clinical nursing experience required
Experience with EHR systems required
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

Nice To Haves

Experience in primary care, internal medicine, geriatrics, family practice, or care coordination preferred
Familiarity with Medicare CCM billing guidelines preferred

Responsibilities

Identify and enroll eligible patients into the CCM program per CMS guidelines
Educate patients about program benefits and obtain required consents
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
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
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