Registered Nurse – Care Management

What You’ll Do

Annual Wellness Visit (AWV) Chart Preparation

· 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.

Care Management & Clinical Oversight

· 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.

Care Navigation & Gap Closure

Actively work in care navigation to:

· 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.

Documentation, Quality & Compliance

· 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.

What We’re Looking For

Required

· Active, unrestricted Registered Nurse (RN) license in a compact state

· Ability and willingness to obtain additional state licenses upon hire (company paid)

· Minimum 3 years of clinical nursing experience to include bedside, Primary Care, Med/Surge, or Home Health 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

Preferred

· 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

Work Location Requirement

This is a remote U.S.-based position. Employees must perform all work physically within the United States. International work is not permitted during scheduled work hours.

Work Environment

This is a remote position and may be “on camera” at any time. The Registered Nurse will work from a home office, requiring reliable internet connectivity and a secure, private workspace.

Technical Requirements:

Computer:
Windows or Apple (macOS) Computer ONLY (NO Chromebooks, Linux Machines, or Smartphones)
Must have at least Windows 10 or macOS 14 Sonoma.
Hardware:
Processor: Intel Core i5 or AMD Equivalent (Windows); Apple Silicon (Macs)
RAM: 16 GB
Headphones: Wired headphones required for optimal audio quality. (NO built-in mics)
Internet Speed: Meet minimum internet speed requirements (100 MBPS download speed and 50 MBPS upload speed). Must have an ethernet cable connecting computer directly into router.
Browser and System: Use Google Chrome with Amazon Workspaces (regardless of computer type). 
Webcam: A webcam is required for video calls. Most laptops have a built-in webcam, which is acceptable. If your computer does not have a webcam, you will need to use an external webcam.
Recommended Equipment: A second monitor is highly suggested for laptop users; dual monitors for PC users.