Registered Nurse - Chronic Care Management

316 Healthcare•Bremen, GA

About The Position

The Registered Nurse specializing in Chronic Care Management (CCM) supports patients managing multiple chronic conditions through personalized, continuous care. The role includes developing and updating care plans, assessing patients during home visits, coordinating with healthcare providers, and educating patients on condition management and prescribed treatments. The nurse also documents patient interactions and care plan updates in electronic health records and manages CCM billing claims.

Requirements

Valid Registered Nurse (RN) license in Georgia.
Strong communication and interpersonal skills.
Ability to work independently and manage a caseload effectively.
Knowledge of healthcare billing and coding procedures.
Compassionate, patient-centered approach to care.
Proficiency with electronic health records and telehealth technology.

Nice To Haves

Experience in chronic disease management.

Responsibilities

Conduct monthly phone updates with patients who have three or more chronic conditions expected to last 12 months or longer.
Develop, implement, and update individualized care plans tailored to each patient's needs.
Perform home visits to assess patient health status and provide necessary support.
Coordinate with healthcare providers to ensure continuity of care.
Manage and submit billing claims related to CCM services accurately and timely.
Document patient interactions and care plan updates thoroughly in electronic health records.
Educate patients on managing their conditions and adhering to prescribed treatments.