Remote CCM RN: Chronic Care Navigator

Dimer Health; EE. UU.; A distancia; USD 80.000 - 90.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

Paid time off

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Panel management

Care planning

Disease monitoring

Care coordination

Medication support

Documentation & billing

Protocols & workflows

Descripción del empleo

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.