Chronic Care Management RN – Home Visits & Care Plans

316 Healthcare; Bremen (GA); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

316 Healthcare is seeking a Registered Nurse specializing in Chronic Care Management (CCM) to develop and update personalized care plans for patients with multiple chronic conditions. The role emphasizes proactive, continuous care and close coordination with healthcare providers.

You will conduct monthly updates, perform home visits, and document all care plans and patient interactions in EHRs, while educating patients on treatment adherence and self-management.

Qualifications

• Valid Registered Nurse (RN) license in Georgia required.
• Experience in chronic disease management preferred.
• Strong communication and interpersonal skills.
• Ability to work independently and manage a caseload effectively.
• Knowledge of healthcare billing and coding procedures.
• Compassionate, patient-centered approach to care.
• Proficiency with electronic health records and telehealth technology.

Responsibilities

• Conduct monthly phone updates with patients who have three or more chronic conditions expected to last 12 months or longer.
• Develop, implement, and update individualized care plans tailored to each patient's needs.
• Perform home visits to assess patient health status and provide necessary support.
• Coordinate with healthcare providers to ensure continuity of care.
• Manage and submit billing claims related to CCM services accurately and timely.
• Document patient interactions and care plan updates thoroughly in electronic health records.
• Educate patients on managing their conditions and adhering to prescribed treatments.

Skills

RN license (GA)

Chronic disease management

Communication skills

Independent work

Billing and coding knowledge

Compassionate care

EHR/telehealth proficiency

Job description

316 Healthcare is seeking a Registered Nurse specializing in Chronic Care Management (CCM) to develop and update personalized care plans for patients with multiple chronic conditions. The role emphasizes proactive, continuous care and close coordination with healthcare providers.

You will conduct monthly updates, perform home visits, and document all care plans and patient interactions in EHRs, while educating patients on treatment adherence and self-management.