RN, Chronic Care Specialist

Senscio Systems • Portland, ME

2d • Remote

About The Position

Senscio Systems is seeking a compassionate, detail-oriented Registered Nurse to provide virtual Chronic Care Management (CCM) and Remote Patient Management (RPM) for patients with multiple chronic conditions. The RN provides ongoing telephonic support, care coordination, patient education, and documentation, helping support proactive outreach, continuity of care, timely follow-up, and improved health outcomes.

The role includes regular communication with supervising nurse practitioners, staff nurses, and engagement specialists. The nurse supports patients managing conditions such as diabetes, hypertension, chronic kidney disease, cancer, congestive heart failure, and mental health conditions. Senscio's Ibis program enables collaboration between care team members and patients at home, using an internet-enabled touchscreen tablet to provide daily care-plan reminders and capture vital signs and symptoms. The system uses clinical AI to identify longitudinal trends and predict possible health exacerbations.

This is a full-time, remote position based in Maine, requiring an active Maine RN license. Work is conducted from home using secure, HIPAA-compliant systems. The position is listed as an immediate need and offers training on CCM requirements, EHR workflows, and documentation standards.

Requirements

• Active, unrestricted RN license; Maine licensure is required.
• Minimum of 1–2 years of clinical experience.
• Strong communication, assessment, critical-thinking, and patient-engagement skills.
• Ability to work independently, manage time effectively, and maintain consistent follow-up.
• Reliable internet connection and a quiet workspace for patient calls.

Nice To Haves

• Additional RN licenses in Michigan, Illinois, Massachusetts, New Hampshire, Rhode Island, Connecticut, Pennsylvania, and Florida; a multistate license is strongly preferred.
• Clinical experience in primary care, internal medicine, case management, home health, or care coordination.
• Experience with chronic disease management, such as diabetes, hypertension, COPD, or CHF.
• Familiarity with CCM documentation requirements and workflows.
• Proficiency with EHR systems and comfort using remote communication technologies.
• Availability for after-hours EHR monitoring and weekend on-call support.

Responsibilities

• Conduct monthly CCM telephone encounters with eligible patients, for a minimum of 20 minutes per patient per month.
• Develop, update, and document individualized, patient-centered comprehensive care plans.
• Perform ongoing medication reconciliation and review patients’ medication lists.
• Assess patient health status, medication adherence, symptoms, and care-plan progress.
• Monitor remote patient vital signs and respond appropriately to changing vital-sign trends.
• Educate patients on disease management, lifestyle changes, and medication management.
• Identify barriers to care and collaborate with Senscio staff and providers to address gaps.
• Maintain accurate, detailed, and timely documentation in the electronic health record.
• Identify and support needs within the clinical team, responding as identified or delegated by supervisory staff.
• Monitor and respond to patient messages, alerts, and care needs within defined timeframes.
• Support care transitions, including post-hospital or post-ED follow-up when needed.
• Comply with CMS CCM program requirements, HIPAA regulations, and organization protocols.
• Communicate closely with supervising nurse practitioners, staff nurses, and engagement specialists to support comprehensive patient care management.

Benefits

• Competitive pay.
• Paid time off (PTO).
• Paid holidays.
• 401(k).
• Various insurance programs.
• Reimbursement for additional licenses and required CEUs.
• Opportunities for promotion and career advancement.
• Training on CCM requirements, EHR workflows, and documentation standards.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed