Remote RN: Chronic Care Management Specialist

Senscio Systems; Portland (ME); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

PTO

401(K)

Health insurance

License reimbursement

Job summary

Senscio Systems seeks a compassionate RN for a full-time, remote CCM/RPM role. You will provide telephonic care coordination, patient education, and documentation for patients with multiple chronic conditions from home.

The position focuses on proactive outreach, continuity of care, and timely follow-up. You will work with a care team to optimize health outcomes and support aging adults in managing their health at home.

Qualifications

• Active, unrestricted RN license (ME required).
• 1–2 years clinical experience in primary care or care coordination.
• Experience with chronic disease management (diabetes, hypertension, CHF).
• Familiarity with CCM documentation and workflows.

Responsibilities

• Conduct monthly CCM telephone encounters (min 20 min per patient).
• Develop, update and document individualized care plans.
• Ongoing medication reconciliation and review of patient lists.
• Assess health status, adherence, symptoms and plan progress.
• Remote Patient Monitoring duties: monitor vitals and respond to trends.
• Provide patient education on disease management and lifestyle changes.
• Identify barriers to care and coordinate with the team to address gaps.
• Maintain accurate documentation in the EHR and respond to messages.
• Support care transitions post-hospitalization or post-ED visits.
• Ensure compliance with CMS CCM, HIPAA, and organizational protocols.

Skills

Telehealth coordination

Care coordination

Patient education

Communication skills

Education

Registered Nurse license (ME)

Tools

EHR software

Job description

Senscio Systems seeks a compassionate RN for a full-time, remote CCM/RPM role. You will provide telephonic care coordination, patient education, and documentation for patients with multiple chronic conditions from home.

The position focuses on proactive outreach, continuity of care, and timely follow-up. You will work with a care team to optimize health outcomes and support aging adults in managing their health at home.