Chronic Care Management Nurse

Job Summary We are seeking a dedicated and compassionate Chronic Care Management Nurse to join our dynamic healthcare team. In this vital role, you will coordinate comprehensive care plans for patients with complex, chronic conditions, ensuring they receive personalized, continuous support. Your expertise will help improve health outcomes, enhance patient satisfaction, and promote proactive management of long-term health issues. This position offers an exciting opportunity to make a meaningful difference in the lives of patients by providing expert nursing care within a collaborative environment. Responsibilities Conduct thorough patient assessments, including vital signs, medical history review, and physiological evaluations to inform individualized care plans. Manage and coordinate chronic care programs by developing tailored treatment strategies that incorporate medication management, lifestyle modifications, and health coaching. Utilize electronic health record (EHR) systems such as Athenahealth to document patient interactions accurately and maintain comprehensive medical records. Collaborate with multidisciplinary teams—including physicians, specialists in ophthalmology, cardiology, and behavioral health—to ensure seamless continuity of care. Provide patient education on disease management, medication adherence, and preventive health measures aligned with NCQA standards. Monitor patient progress through regular follow-ups via telehealth or in-person visits; adjust care plans based on clinical findings and patient feedback. Assist with complex procedures such as IV infusions, suturing, catheterization, and sterile techniques when necessary to support ongoing patient needs. Requirements Valid nursing license with current registration; experience in medical-surgical, critical care, or long-term care settings preferred. Demonstrated proficiency with EMR/EHR systems including Epic, Cerner, or eClinicalWorks; familiarity with

ICD-10/ICD-9

coding is highly desirable. Strong clinical skills encompassing vital signs assessment, medication administration, laboratory specimen collection/processing, and infection control protocols. Experience working with diverse patient populations such as seniors in assisted living or memory care facilities; familiarity with geriatrics and dementia care is a plus. Knowledge of advanced nursing procedures including IV insertion, ventilator management, tube feeding techniques, and aseptic technique. Ability to perform comprehensive patient assessments involving anatomy knowledge and physiology understanding; capable of triage and acute pain management. Excellent communication skills for effective patient education and team collaboration; experience working with people with disabilities or developmental challenges is advantageous. Certifications in basic life support (BLS), sterile processing, or specialized areas like hospice & palliative medicine are preferred. Join our team to deliver innovative chronic care solutions that empower patients to live healthier lives! We are committed to fostering an inclusive environment where your expertise makes a real impact on community health outcomes every day.

Job Type:

Full-time Pay:

$20.00 - $24.00 per hour

Benefits:

401(k) Dental insurance Life insurance Paid time off Retirement plan Vision insurance

Work Location:

In person