Chronic Care Management (CCM) RN

Dimer Health; United States; Remote; USD 80,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Job summary

Dimer Health is seeking a CCM Registered Nurse to lead frontline care for patients with multiple chronic conditions, remotely. You will manage a dedicated CCM panel, conduct regular monitoring, update care plans, and proactively reach out to patients in coordination with physicians and care teams.

The role includes clinical triage, inbox management, and involvement in RN workflow improvements. Offers full-time employment with PTO and an HRA, plus a base salary range of $80,000–$90,000.

Qualifications

• You will carry a CCM patient panel and be evaluated on patient engagement, monthly minutes delivered, and care gap closure.
• Provide backup RN coverage including clinical triage and patient inbox management on a rotating schedule with some evenings, weekends, and holidays.
• Participate in developing RN workflows, quality metrics, and protocols.

Responsibilities

• Own day-to-day care of the CCM patient panel with regular check-ins, symptom monitoring, goal setting, and care plan updates.
• Develop and maintain comprehensive, patient-centered care plans with patients, caregivers, and the care team.
• Track chronic disease indicators (BP, glucose, weight) and identify signs of decompensation.
• Coordinate with physicians, APPs, and case managers to adjust treatment plans and close care gaps.
• Support medication reconciliation and adherence for complex regimens.
• Document time and services accurately for CMS CCM billing and compliance.
• Follow CCM protocols (CHF, COPD, diabetes, hypertension, CKD) and share input to improve workflows.
• Provide backup clinical coverage including triage by phone/video/secure messaging and patient inbox management.
• Educate patients with clear guidance and follow-up instructions.
• Maintain HIPAA and telehealth privacy standards and participate in quality reviews.

Skills

Panel management

Care planning

Disease monitoring

Care coordination

Medication support

Documentation & billing

Protocols & workflows

Job description

Deliver Chronic Care Management services to patients with multiple chronic conditions as they transition out of acute care, serving as their consistent point of contact through regular monitoring, care plan updates, and proactive outreach.

About the Role

Chronic Care Management is a core pillar of Dimer Health's growth strategy. As a CCM RN, you'll deliver frontline CCM services to patients with multiple chronic conditions as they transition out of acute care. You'll be their consistent point of contact, providing regular monitoring, care plan updates, and proactive outreach in close collaboration with physicians, advanced practice providers, and case managers.

You’ll carry a CCM patient panel and be measured on patient engagement, monthly minutes delivered, and care gap closure. You’ll also provide backup RN coverage, including clinical triage and patient inbox management, on a rotating schedule that includes some evenings, weekends, and holidays. As the program grows, you’ll contribute ideas on RN workflows, quality metrics, and protocols.

What You'll Do

In this role you will own the day-to-day care of your CCM patient panel and help shape the program as it grows:

• Panel management - Manage a panel of patients with two or more chronic conditions through regular check-ins, symptom monitoring, goal setting, and care plan updates.
• Care planning - Develop and maintain comprehensive, patient-centered care plans with patients, caregivers, and the care team.
• Disease monitoring - Track chronic disease indicators such as blood pressure, glucose, and weight, and proactively identify signs of decompensation.
• Care coordination - Work with physicians, advanced practice providers, and case managers to adjust treatment plans and close care gaps.
• Medication support - Support medication reconciliation and adherence for patients on complex regimens.
• Documentation & billing - Accurately document time and services delivered in line with CMS CCM billing and compliance requirements.
• Protocols & workflows - Follow evidence-based CCM protocols (CHF, COPD, diabetes, hypertension, CKD) and standardized RN workflows, and share frontline input to improve them.

You will also provide backup RN clinical coverage and uphold our quality standards:

• Clinical triage - Provide backup triage by phone, video, and secure messaging, assessing symptoms, identifying red flags, and determining appropriate disposition.
• Patient inbox - Cover the patient inbox as backup, reviewing and responding to messages within defined service-level expectations.
• Protocol-based care - Use Dimer Health's problem-specific protocols within RN scope of practice and elevate to providers when clinical complexity warrants.
• Patient education - Give patients clear education, self-care guidance, and follow-up instructions.
• Privacy & quality - Maintain HIPAA and telehealth privacy standards and participate in documentation and quality reviews as requested.

The base salary range for this role is $80,000 - $90,000. This range reflects the minimum and maximum target for new hire salaries across all locations. Within it, individual pay is determined by job-related skills, experience, and relevant education or training. We typically make offers near the midpoint of the range.

This is a full-time, benefits-eligible role with paid time off and a Health Reimbursement Arrangement (HRA). The HRA reimburses eligible medical, dental, or vision expenses, including the cost of an individual health plan purchased through your state's Health Insurance Marketplace, up to a set amount each year. Basic life insurance is also provided, with the premium paid in full by Dimer Health.

Why Join Us

Dimer Health is a physician-led virtual medical practice that takes short-term clinical ownership of the critical 30-day recovery window, helping patients safely transition home from hospitals, skilled nursing facilities (SNFs), and other acute and post-acute care settings.

As a CCM RN, you'll make a meaningful difference in outcomes, access, and experience for patients managing multiple chronic conditions. You'll work fully remotely in a collaborative, team-based virtual care environment alongside physicians, advanced practice providers, and case managers. Our model combines a physician-led medical practice with proprietary technology and AI-driven insights, and your frontline perspective will help shape how our RN workflows, quality metrics, and protocols evolve.

Chronic Care Management is central to Dimer Health's future growth. As the program scales, so do the opportunities for professional growth, and for the right person, this role offers room to take on more responsibility as Dimer continues to expand.

We believe the biggest opportunities for AI in healthcare won’t come from applying AI to existing workflows, but from using it to fundamentally rethink how care is delivered. That’s what excited us about Dimer: they’re combining AI with real clinical expertise to create a more connected, accessible model of care that extends beyond the traditional healthcare setting. And the numbers on improved outcomes prove that model is working.

Partner, SilverCircle

Dimer has significantly improved both pre- and post-operative care for our patients. Pre-operatively, patients are seeing the appropriate specialists, getting cleared, and being closely monitored, helping reduce case cancellations due to uncontrolled medical comorbidities. Post-operatively, we’re seeing fewer calls related to pain management, nausea, and constipation, while helping reduce unnecessary readmissions.

Dimer Health allows me to make sure that each and every one of my patients remains healthy after surgery. Their caring attitude goes above and beyond. Couldn't be taking care of our patients without them!

Dr. Lee F. Starker

Surgical Oncologist

Since partnering with Dimer Health, we've seen a 70% reduction in missed OR case opportunities and a 100% Net Promoter Score from our joint replacement patients. It's made the overall total joint replacement procedure noticeably smoother and safer.

Orthopedic Surgeon

Since partnering with Dimer, we've seen after-hours calls decrease by approximately 75%. At the same time, we've been able to better meet our patients' needs around the clock while reducing the burden on our physicians and improving physician satisfaction.

Urologic Oncologist

Our collaboration with Dimer Health gives my patients an extra hand to hold during their recovery. This access reduces anxiety and prevents complications.

The Dimer model has allowed us to make that connection after patients leave our hospital through their Transitionists. It’s been working so well that we’re now looking to expand the model across additional units.

President & CEO, Bergen New Bridge Medical Center

Dimer is a rare example of a healthcare solution that delivers a true win for every stakeholder: patients, providers, and payers. Very few companies can simultaneously improve patient experience and outcomes, reduce the burden on providers, and lower costs across the system, all while harnessing cutting-edge AI in a responsible and impactful way.

Managing Partner, Team8

We believe the biggest opportunities for AI in healthcare won’t come from applying AI to existing workflows, but from using it to fundamentally rethink how care is delivered. That’s what excited us about Dimer: they’re combining AI with real clinical expertise to create a more connected, accessible model of care that extends beyond the traditional healthcare setting. And the numbers on improved outcomes prove that model is working.

Partner, SilverCircle

Dimer has significantly improved both pre- and post-operative care for our patients. Pre-operatively, patients are seeing the appropriate specialists, getting cleared, and being closely monitored, helping reduce case cancellations due to uncontrolled medical comorbidities. Post-operatively, we’re seeing fewer calls related to pain management, nausea, and constipation, while helping reduce unnecessary readmissions.

Dimer Health allows me to make sure that each and every one of my patients remains healthy after surgery. Their caring attitude goes above and beyond. Couldn't be taking care of our patients without them!

Dr. Lee F. Starker

Surgical Oncologist

Since partnering with Dimer Health, we've seen a 70% reduction in missed OR case opportunities and a 100% Net Promoter Score from our joint replacement patients. It's made the overall total joint replacement procedure noticeably smoother and safer.

Orthopedic Surgeon

Since partnering with Dimer, we've seen after-hours calls decrease by approximately 75%. At the same time, we've been able to better meet our patients' needs around the clock while reducing the burden on our physicians and improving physician satisfaction.

Urologic Oncologist

Our collaboration with Dimer Health gives my patients an extra hand to hold during their recovery. This access reduces anxiety and prevents complications.

The Dimer model has allowed us to make that connection after patients leave our hospital through their Transitionists. It’s been working so well that we’re now looking to expand the model across additional units.

President & CEO, Bergen New Bridge Medical Center

Dimer is a rare example of a healthcare solution that delivers a true win for every stakeholder: patients, providers, and payers. Very few companies can simultaneously improve patient experience and outcomes, reduce the burden on providers, and lower costs across the system, all while harnessing cutting‑edge AI in a responsible and impactful way.