Remote Ambulatory Chronic Care RN: Care Coordination Leader

Jobgether; United States; Remote; USD 51,000 - 115,000; Full time

Benefits offered by this job

Remote flexibility

Healthcare coverage

Retirement benefits

Paid leave

Education and professional growth

Job summary

Jobgether partners are seeking an Ambulatory Chronic Care Manager (RN) to improve outcomes for patients with chronic conditions. The role emphasizes care coordination, clinical assessment, and patient engagement in a primarily remote setting with travel to onsite locations for onboarding and training.

Responsibilities include developing care plans, coordinating transitions, and applying evidence-based practices to patient interventions.

Qualifications

• Bachelor's degree in a clinically related field.
• Active RN license in Connecticut.
• ≥3 years direct patient care and care coordination experience.
• CCM credential or equivalent preferred.
• Strong knowledge of chronic disease management and care transitions.
• Excellent communication and collaboration skills.

Responsibilities

• Conduct nursing assessments to identify patient needs, risks, and gaps in care.
• Enroll eligible patients in chronic care programs and maintain engagement.
• Develop and implement individualized care plans and action steps.
• Coordinate transitions between healthcare settings and support continuity of care.
• Perform medication reconciliation and reviews for safety and efficacy.
• Provide patient education on chronic conditions and self-care strategies.
• Assess social determinants of health impacting access and adherence.
• Collaborate with multidisciplinary teams during rounds to optimize resource use.
• Contribute to improvement plans addressing care coordination issues.

Skills

Care coordination

Chronic disease management

Motivational interviewing

Communication skills

Time management

Education

Bachelor's degree in a clinically related field

Tools

EHR systems

Microsoft Office

Job description

Jobgether partners are seeking an Ambulatory Chronic Care Manager (RN) to improve outcomes for patients with chronic conditions. The role emphasizes care coordination, clinical assessment, and patient engagement in a primarily remote setting with travel to onsite locations for onboarding and training.

Responsibilities include developing care plans, coordinating transitions, and applying evidence-based practices to patient interventions.