Registered Nurse – Virtual Care & Care Management (Remote)

CareTalk Health

1d•Remote

About The Position

CareTalk Health is seeking experienced and highly organized Registered Nurses to join our virtual care team. This fully remote role blends care management, care navigation, and Annual Wellness Visit (AWV) chart preparation, supporting providers in delivering comprehensive, compliant, and patient-centered care. The RN Care Manager will manage medically complex patients, develop and monitor care plans across multiple programs (CCM, RPM, RTM, APCM), complete AWV chart preparation, and actively work to close care gaps, coordinate orders, and support preventive and chronic care initiatives. This role requires strong clinical judgment, excellent documentation skills, comfort with telehealth workflows, and the ability to work independently across multiple platforms.

Requirements

Active, unrestricted Registered Nurse (RN) license in a compact state
Ability and willingness to obtain additional state licenses upon hire (company paid)
Minimum 2–3 years of clinical nursing experience
Experience providing care in a telehealth or virtual care setting
Experience working remote
Experience in one or more of the following: Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Telehealth or virtual care coordination, Primary care or care management
Proficiency with EHR systems and telehealth platforms
Strong clinical assessment and care coordination skills
Excellent verbal and written communication skills
High level of organization, attention to detail, and time management
Ability to work independently in a remote environment
Commitment to patient-centered, culturally competent care
Dedicated, private home workspace
Computer: Windows or Apple Computer ONLY (NO Chromebooks, Linux Machines, or Smartphones) Must have at least Windows 10 or MacOS 13.
Headphones: Wired headphones required for optimal audio quality.
Internet Speed: Meet minimum internet speed requirements (50 MBPS download speed and 20 MBPS upload speed), with a wired connection to the router. Must have an ethernet cable connecting computer directly into router.
Browser and System: Use Google Chrome with Amazon Workspaces (regardless of computer type).
Video Capability Required: Required for video calls. (Webcam) Laptops will come with a built in webcam which is fine. If it doesn’t you’ll need to get one.
Recommended Equipment: A second monitor is suggested for laptop users; dual monitors for PC users.

Nice To Haves

Experience with Medicare Annual Wellness Visits (AWVs)
Knowledge of CMS documentation and preventive care guidelines
Certification in case management or gerontological nursing
Experience working across multiple virtual care programs and platforms

Responsibilities

Prepare comprehensive AWV charts to support provider efficiency and CMS compliance.
Review and summarize with patients in face-to-face virtual visits via Zoom: Medical, surgical, and family histories, Medication lists and adherence, Preventive screenings and immunizations, Cognitive, functional, and depression assessments.
Identify overdue screenings, risk factors, and care gaps prior to visits.
Communicate concise patient summaries and key findings to providers before each AWV.
Coordinate with patients to obtain missing or clarified information as needed.
Ensure documentation meets Medicare, CMS, and organizational requirements.
Provide telephonic and portal-based care management for medically complex patients with chronic, behavioral health, and socio-economic comorbidities.
Conduct comprehensive nursing assessments addressing: Physical, functional, psychological, social, environmental, and learning needs.
Develop, implement, and monitor individualized care plans for: CCM, RPM, RTM, and APCM.
Complete care plan creation and annual updates for APCM, including goal-setting, interventions, and progress tracking.
Utilize motivational interviewing to engage patients and caregivers in care planning and adherence.
Monitor patient progress, reassess goals, identify barriers, and adjust care plans as needed.
Communicate patient status and care plan updates to primary care providers and interdisciplinary care teams.
Provide patient education, coaching, and support aligned with health literacy and cultural needs.
Act as a patient advocate and assist with problem-solving and escalation when appropriate.
Identify and close care gaps (preventive screenings, labs, medications, follow-ups).
Coordinate and facilitate orders, referrals, and follow-up actions as needed.
Monitor service delivery to ensure appropriateness, avoid duplication, and meet patient needs.
Coordinate care across multiple services and providers to ensure continuity and quality.
Maintain accurate, timely, and confidential patient records.
Utilize electronic health record systems (CT360, RXNT, Zoom) and telehealth platforms effectively.
Measure and support outcomes related to clinical quality, patient engagement, and satisfaction.
Adhere to HIPAA, CMS, and organizational compliance standards.
Participate in professional development and ongoing training.
Demonstrate strong, independent decision-making, prioritization, and multitasking skills.
Perform other duties as assigned.