Nurse Practitioner Chronic Care Management

Benefits:

Competitive salary Flexible schedule Opportunity for advancement

About Us:

We are a growing home care agency expanding our Chronic Care Management (CCM) and care coordination services to better support patients with multiple chronic conditions. Our mission is to improve outcomes, reduce hospitalizations, and provide proactive, patient-centered care in collaboration with caregivers, families, and providers.

Position Summary:

We are seeking a Nurse Practitioner (NP) to lead and support our Chronic Care Management program . This role focuses on care coordination, clinical oversight, patient education, and interdisciplinary collaboration for patients with two or more chronic conditions. The ideal candidate is organized, compassionate, and experienced in managing complex patients outside of traditional office visits. Key Responsibilities Conduct comprehensive in person CCM assessments and ongoing monthly care management. Monthly management is done remotely. Develop, implement, and update individualized care plans Monitor chronic conditions (e.g., CHF, COPD, diabetes, hypertension, dementia) Coordinate care with physicians, specialists, caregivers, and community resources Provide patient and family education and support via phone or telehealth Identify gaps in care and intervene proactively to prevent hospitalizations Document CCM activities accurately in accordance with Medicare guidelines Support compliance with CMS CCM requirements and quality measures Collaborate with agency leadership to grow and enhance the care management program Qualifications Active Nurse Practitioner license (state-specific) National NP certification (AANP or ANCC) Minimum 2 years of clinical experience (primary care, geriatrics, home care, or care management preferred) Experience with chronic disease management and care coordination Familiarity with Medicare CCM services and documentation requirements (preferred) Strong communication, organization, and time-management skills Comfortable working independently in a remote or hybrid environment EMR experience required What We Offer Competitive compensation Flexible schedule (ideal for work-life balance) Opportunity to help build and shape a growing CCM program Collaborative, mission-driven work environment Supportive leadership and administrative support Flexible work from home options available.