Remote CCM RN: Care Coordination & Outreach

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

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