LPN - Chronic Care Management: Primary Care

AuthoraCare Collective • Greensboro, NC

32d • Remote

About The Position

Our Mission: AuthoraCare Collective empowers people to be active participants in their care journey, enabling them to live on their own terms through personalized support for mind, body, and spirit. Our patients are always the author of their life story. During a challenging illness, AuthoraCare Collective helps them author more moments that matter, regardless of the stage of their illness or condition. This is captured by our tagline: Your Story. Our Expert Care. AuthoraCare Collective is currently seeking an LPN for our Primary Care Chronic Care Management supporting our High Point, Kernersville and Winston-Salem service areas. This LPN Chronic Care Management position is Full-Time: Monday - Friday 8:00am - 5:00pm and will be primarily remote after successful completion of training and demonstration of competency in workflows and documentation. The LPN for Chronic Care Management provides coordinated, patient-centered support to individuals living with multiple chronic conditions. This role focuses on assisting patients with care plan development, ongoing monitoring, education, outreach, and communication to improve health outcomes, reduce hospitalizations, and enhance quality of life. The LPN collaborates closely with providers, RN Care Coordinators, and interdisciplinary team members to ensure continuity of care and adherence to evidence-based guidelines.

Requirements

• Active, unencumbered LPN license in the applicable state.
• Minimum 1-2 years of clinical nursing experience (primary care, home health, care management, or chronic disease experience preferred).
• Strong assessment, communication, and problem-solving skills.
• Proficiency in EMR systems and comfort with technology.
• Ability to work independently while contributing effectively to a team.
• Other: Valid state-issued driver's license required. Must carry automobile liability insurance at limits required by agency. Must have own transportation.

Nice To Haves

• Experience in chronic disease management, population health, or care coordination.
• Knowledge of CCM program requirements and value-based care models.
• Bilingual skills a plus.

Responsibilities

• Conduct monthly CCM outreach to enrolled patients, assessing symptoms, medication adherence, lifestyle factors, and barriers to care.
• Support the development and ongoing review of individualized care plans under RN and provider supervision.
• Provide patient education on chronic conditions, medications, and self-management strategies.
• Monitor changes in patient status and escalate clinical concerns to the RN or provider as appropriate.
• Demonstrates strong clinical judgment in triaging patient needs effectively.
• Facilitate communication between patients, caregivers, providers, and community resources.
• Assist with coordination of appointments, diagnostic tests, and referrals.
• Consistently meets follows up with patients promptly to ensure continuity of care.
• Ensure timely follow-up after hospitalizations, ED visits, or changes in treatment plans.
• Track and document interventions, patient interactions, and progress toward care plan goals.
• Maintain accurate, timely, and compliant documentation in the electronic medical record (EMR).
• Ensure CCM interactions meet all regulatory requirements to support program billing and reporting.
• Follow organizational protocols, clinical guidelines, and scope-of-practice limitations.
• Consistently meets the monthly touchpoint goal by completing timely, effective patient outreach and documentation.
• Participate in interdisciplinary care conferences, huddles, and case reviews.
• Work collaboratively with clinical and administrative staff to support efficient workflows.
• Communicate patient needs, trends, and barriers to the care team to support proactive care.
• Contribute to quality initiatives aimed at reducing hospital/ED utilization, improving chronic disease management, and enhancing patient experience.
• Identify opportunities to strengthen CCM processes and help implement workflow improvements.

Benefits

• Competitive salaries and a comprehensive benefit package which includes paid time off (PTO), seven paid holidays, medical, dental, vision, disability, and life insurance, and 403B match after 12 months of service.
• Other benefits include mileage reimbursement, flexible work schedules, professional growth and development opportunities, and employee engagement activities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Nursing and Residential Care Facilities
• Education Level: No Education Listed
• Number of Employees: 251-500 employees