Registered Nurse | Chronic Care Management

Oak Medical•Remote, US,

2d•Remote

About The Position

Oak Medical is looking for a Critical Care Management Registered Nurse (CCM RN) to join their team and help support the ongoing healthcare needs of patients with chronic conditions in long-term care and senior living settings. This is an excellent opportunity for a nurse who enjoys being a clinical resource and advocate while working closely with patients, families, facility staff, providers, and other healthcare professionals. This is a full-time, remote position. The CCM RN may occasionally travel to our corporate office in Waukesha, Wisconsin for training.

Requirements

Current, unrestricted Wisconsin RN license
Strong clinical assessment and critical thinking skills
Excellent communication and interpersonal skills
Ability to manage multiple priorities and respond appropriately to time-sensitive clinical concerns
Ability to work independently while collaborating effectively with a multidisciplinary team
Knowledge of geriatric care and the unique healthcare needs of seniors
Familiarity with electronic health records

Nice To Haves

BSN
Certification in Gerontology or Chronic Care Management (CCM)
Experience in triage, senior living, long-term care, care coordination, or a similar nursing role
Experience with Medicare Part B Chronic Care Management programs or CMS quality reporting

Responsibilities

Provide clinical triage by responding to calls, electronic messages, and health concerns from patients, families, facility staff, and care partners.
Use clinical judgment and assessment skills to determine the appropriate level of care, from routine follow-up and education to provider notification or urgent escalation.
Conduct telephonic, electronic, and occasional in-person assessments related to symptoms, changes in condition, chronic conditions, medications, and other health concerns.
Develop and maintain individualized care plans in collaboration with patients, families, facility staff, providers, and the healthcare team.
Coordinate referrals, medication questions, lab and order clarification, DME needs, prior authorizations, follow-up care, and other patient needs.
Provide education and reassurance to patients, families, and facility staff regarding chronic disease management, medications, preventive care, symptom monitoring, and when to seek additional medical attention.
Monitor patients' needs and follow-up plans, ensuring recommendations and provider-directed interventions are completed timely.
Accurately document clinical encounters, assessments, interventions, care coordination, and follow-up in accordance with established protocols and regulatory requirements.
Support Medicare Part B Chronic Care Management (CCM) services and documentation requirements.
Collaborate with a multidisciplinary team to identify opportunities to improve the quality and coordination of care for our patients.