Chronic Care Management Nurse (RN)

Johnson County Hospital•Tecumseh, NE

3d•Onsite

About The Position

The Chronic Care Management (CCM) Nurse is responsible for coordinating, monitoring, and managing care for patients with multiple chronic conditions in a Rural Health Clinic setting. This role supports improved patient outcomes, reduces avoidable hospital utilization, and ensures compliance with Centers for Medicare and Medicaid Services (CMS) Chronic Care Management requirements. The CCM nurse serves as the primary clinical point of contact for enrolled patients, providing ongoing assessment, education, care coordination, and documentation required to support quality care delivery and appropriate reimbursement.

Requirements

Active Registered Nurse (RN) license in the State of Nebraska
Graduation from an accredited nursing program (AND or BSN).
Minimum of 2 years nursing experience, preferably in:
Primary care or outpatient clinic setting.
Rural health or critical access hospital-affiliate clinic.
Chronic disease management, care coordination, or case management.
Strong clinical judgement, organizational, and documentation skills.
Proficiency with electronic health records (EHR).

Nice To Haves

Experience with Chronic Care Management or population health programs.
Knowledge of CMS CCM documentation and billing requirements.
Prior experience in a Rural Health Clinic setting.
Case management or care coordination certification (preferred but not required).

Responsibilities

Identify and enroll patients eligible for CCM services (patients with two or more chronic conditions expected to last at least 12 months or until death).
Educate patients and caregivers regarding the CCM program and obtain documented consent in accordance with CMS requirements.
Develop, implement, and maintain comprehensive, individualized care plans, including:
Active problem list and chronic conditions monitoring.
Medication management and reconciliation
Functional, psychological, and support needs.
Coordination with community and specialty services.
Serve as the primary clinical contact for CCM patients between face-to-face visits.
Provide disease-specific education, self-management support, and preventive care reinforcement.
Coordinate care with providers, specialists, hospitals, home health agencies, skilled nursing facilities, and community resources.
Monitor patient status and identify changes in condition requiring provider notification.
Assist with transitions of care following hospital or skilled nursing facility discharges, when applicable.
Support medication adherence and identify potential medication-related concerns.
Accurately document CCM activities, patient communications, care plans, and time spent in the electronic health record (EHR).
Track CCM time monthly to meet CMS billing thresholds.
Collaborate with billing and administrative staff to support accurate CCM claim submission.
Maintain compliance with CMS, RHC regulations, HIPAA, and clinic policies and procedures.
Assist with monitoring and improving quality measures related to chronic disease management.
Identify gaps in care and work collaboratively with the healthcare team to address them.
Participate in quality improvement, patient engagement, and population health initiatives.
Work closely with providers, nursing staff, medical assistants, front desk, billing, and leadership teams.
Communicate clearly, professionally, and compassionately with patients, families, and caregivers.
Participate in clinic meetings, care conferences, education, and required training.