Chronic Care Management Registered Nurse

El Centro Family Health•Española, NM

About The Position

Under the direction and supervision of the Director of Nursing or designee, the Chronic Care Management Registered Nurse (CCM RN) coordinates comprehensive care for patients with multiple chronic conditions. This role focuses on proactive care coordination, chronic disease education, patient outreach, and interdisciplinary collaboration to improve patient outcomes, support value-based care initiatives, and ensure compliance with CMS Chronic Care Management requirements. The CCM RN practices in accordance with the New Mexico Nurse Practice Act, CMS guidelines, HRSA/FQHC standards, and organizational policies. What You Will Do: Deliver comprehensive care coordination and chronic disease management by providing patient education, goal-setting support, and the promotion of preventive health practices through telephonic, virtual, or in-person engagement. Perform comprehensive nursing assessments to develop individualized electronic care plans while monitoring chronic disease indicators, treatment adherence, and facilitating seamless transitions of care through post-hospital follow-ups and specialty referrals. Apply independent clinical judgment and critical thinking to assess patient needs. Conduct telephone triage and escalate urgent or emergent concerns appropriately. Review laboratory, imaging, and diagnostic results related to chronic conditions and coordinate follow-up care. Address social determinants of health through referrals to community resources. Document CCM services, patient contacts, care plans, and time tracking accurately in the electronic health record. Ensure compliance with CMS Chronic Care Management billing requirements, HIPAA regulations, HRSA standards, and organizational policies. Participate in audits, reporting, and quality improvement initiatives. Collaborate with providers, medical assistants, behavioral health, pharmacy, clinic nurses, and community health workers. Support population health initiatives, UDS/HEDIS measures, and value-based care goals. Participate in care team meetings, training activities, and workflow development. Maintain accurate and timely EHR documentation. Identify and enroll eligible patients into CCM programs according to CMS, payer, and organizational guidelines. Other duties as assigned.

Requirements

Graduate of an accredited registered nursing program.
Current, unrestricted Registered Nurse license in the State of New Mexico.
Minimum one (1) year of nursing experience in a healthcare setting; chronic disease management, outpatient care, care coordination, or FQHC experience preferred.
Basic Life Support (BLS) certification required.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Experience in community health, FQHC, or primary care setting.
Chronic Care Management or population health experience.
Bilingual English/Spanish, read and write

Responsibilities

Deliver comprehensive care coordination and chronic disease management by providing patient education, goal-setting support, and the promotion of preventive health practices through telephonic, virtual, or in-person engagement.
Perform comprehensive nursing assessments to develop individualized electronic care plans while monitoring chronic disease indicators, treatment adherence, and facilitating seamless transitions of care through post-hospital follow-ups and specialty referrals.
Apply independent clinical judgment and critical thinking to assess patient needs.
Conduct telephone triage and escalate urgent or emergent concerns appropriately.
Review laboratory, imaging, and diagnostic results related to chronic conditions and coordinate follow-up care.
Address social determinants of health through referrals to community resources.
Document CCM services, patient contacts, care plans, and time tracking accurately in the electronic health record.
Ensure compliance with CMS Chronic Care Management billing requirements, HIPAA regulations, HRSA standards, and organizational policies.
Participate in audits, reporting, and quality improvement initiatives.
Collaborate with providers, medical assistants, behavioral health, pharmacy, clinic nurses, and community health workers.
Support population health initiatives, UDS/HEDIS measures, and value-based care goals.
Participate in care team meetings, training activities, and workflow development.
Maintain accurate and timely EHR documentation.
Identify and enroll eligible patients into CCM programs according to CMS, payer, and organizational guidelines.
Other duties as assigned.