Chronic Care Management RN

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

Benefits offered by this job

Remote work

Paid time off

HRA benefits

Life insurance

Job summary

Dimer Health is hiring a Chronic Care Management Registered Nurse (CCM RN) to deliver frontline CCM services to patients with multiple chronic conditions in a fully remote setting. You will manage a CCM patient panel, provide regular monitoring, update care plans, and proactively outreach in collaboration with physicians, APPs, and case managers.

You will also handle backup RN coverage, triage, and patient inbox management on a rotating schedule, contributing to RN workflows and quality metrics

Qualifications

• RN with CCM experience preferred.
• Ability to work remotely and manage a virtual care workflow.
• Experience coordinating with physicians, APPs, and case managers.

Responsibilities

• Panel management: manage a CCM patient panel with regular check-ins and care plan updates.
• Care planning: develop and maintain patient-centered care plans with patients and care team.
• Disease monitoring: track blood pressure, glucose, weight, and decompensation signs.
• Care coordination: adjust treatment plans with clinicians to close care gaps.
• Medication support: reconcile and support adherence for complex regimens.
• Documentation & billing: document time and services per CMS CCM requirements.
• Protocols & workflows: follow CCM protocols and share input to improve them.
• Clinical triage: provide backup triage by phone, video, and secure messaging.
• Patient inbox: respond to messages within SLAs as backup.
• Protocol-based care: use RN protocols and escalate as needed.
• Patient education: provide clear guidance and follow-up instructions.
• Privacy & quality: uphold HIPAA and telehealth privacy standards.

Skills

Panel management

Care planning

Disease monitoring

Care coordination

Medication support

Documentation & billing

Protocols & workflows

Clinical triage

Patient inbox

Privacy & quality

Patient education

Job description

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.

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 escalat 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.

Compensation & Benefits

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.