Chronic Care Management Nurse JobWellington, FL 112605

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Why You'll Love This Job

We are seeking a full-time Chronic Care Nurse to help enhance our delivery of quality patient care in our busy primary care practice in Wellington, Florida.


Chronic Care Management (CCM):
  •  Assisting with the identification, enrollment and management of qualified, high-risk patients.
  •  Development of patient-centered care plans
  • Frequent telephonic reach-out to monitor and revise care plans
  • Coordinate care with patient care team members to improve outcomes
Transitional Care Management (TCM)
  •  Assist with the identification of patients as they transition from ER, inpatient settings, and community rehabilitation centers.
  •  Ensure patients are seen within an appropriate time frame
  • Maintain frequent telephonic communication in the post-transition period to prevent re-admission.
Remote Patient Monitoring (RPM)
  • Assist with the identification of high-risk patients that require remote vitals monitoring
  • Analyze and track remote data and share with the patient care team
  •  Clinical Call Triage
  • Assist with the triage of clinical patient calls from the phone center
  • Assist with the interpretation and relaying of clinical results upon patient request
Nurse Schedule
  •  Maintain a “Nurse Schedule” for timely evaluation of high-risk patients in coordination with the patient’s Primary care provider
  •  CCM enrollment and care plan development
  • RPM set up

Skills & Qualifications

  • Experienced Registered Medical Assistant, LPN, or RN (2 years minimum)
  • Passionate about healthcare and patient experiences
  • Knowledgeable of the most common chronic diseases, standard treatments, and associated pharmaceuticals
  • Outstanding communication and telephone skills
  • Electronic Medical Record experience preferred (EClinical Works)
  •  Works well with others and implements multi-disciplinary approach to improve patient outcomes
  • Detail-oriented and able to multi-task
  • 80% telephone-based tasks, 20% face-to-face patient care
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