RN, Chronic Care Specialist

Senscio Systems; Portland (ME); Remote; USD 70.000 - 90.000; Vollzeit

Benefits dieser Stelle

PTO

401(K)

Health insurance

License reimbursement

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Telehealth coordination

Care coordination

Patient education

Communication skills

Ausbildung

Registered Nurse license (ME)

Tools

EHR software

Jobbeschreibung

Maine Based/Licensed Registered Nurse

Details:

Hiring Company:

Senscio Systems.

Position Available:

Full Time – immediate need.

Position Description:

We are seeking a compassionate and detail-oriented Registered Nurse (RN) to join our team in a full-time, Virtual Chronic Care Management (CCM) and Remote Patient Management (RPM) role. The RN serves at the center of our program, and will provide ongoing telephonic support, care coordination, patient education, and documentation for patients with multiple chronic conditions. This role supports improved health outcomes by ensuring proactive outreach, continuity of care, and timely follow-up.

About Our Company:

Senscio is a rapidly growing virtual health company providing the most effective health management solution for the most complex health. Our mission is to make every day easier for everyone with complex health and those who care for them.

Supporting aging adults to remain independent and manage their health effectively at home, our solutions are purposefully designed for individuals with multiple chronic conditions such as diabetes, hypertension, chronic kidney disease, cancer, congestive heart failure, and mental health conditions. Our approach is to recognize, evaluate, and address health exacerbations in the home to prevent unnecessary acute care.

Senscio provides easy-to-follow personalized, actionable self-care steps aligned to a whole person treatment plan that is derived from integrating the care plans prescribed by an individual’s PCP and specialists. Our Ibis program provides real-time collaboration between care team members and the individual-at-home, enabling triage and health screenings to happen automatically. Patients are provided an internet-enabled, touch-screen tablet which provides them daily care plan reminders. Ibis captures patient’s vitals and symptoms daily and learns longitudinal health trends through clinical AI to predict likely health exacerbations before they occur.

Key Responsibilities:

• Close communication with supervising nurse practitioners, staff nurses, and engagement specialists for comprehensive patient care management including, but not limited to, the following responsibilities:

• Conduct monthly CCM telephone encounters with eligible patients (minimum 20 minutes per patient per month).

• Develop, update, and document individualized, patient-centered comprehensive care plans.

• Ongoing medication reconciliation and review of patients’ medication lists.
• Assess patient health status, medication adherence, symptoms, and care plan progress.
• Remote Patient Monitoring duties include monitoring vital signs and responding appropriately for changing vital sign trends.

• Provide patient education on disease management, lifestyle changes, and medication management.

• Identify barriers to care and collaborate with Senscio staff and providers to address gaps.

• Maintain accurate, detailed, and timely documentation in the electronic health record (EHR).

• Ability to identify and support needs within the clinical team and respond as identified or as delegated by supervisory staff.
• Monitor and respond to patient messages, alerts, or care needs within defined timeframes.

• Support care transitions, including post-hospital or post-ED follow-up when needed.
• Comply with CMS CCM program requirements, HIPAA regulations, and organization protocols.

Qualifications:

• Active, unrestricted RN license (ME licensed required, additional licenses in MI, IL, MA, NH, RI, CT, PA and FL or an overall multi-state strongly preferred).
• Minimum 1–2 years of clinical experience (primary care, internal medicine, case management, home health, or care coordination preferred).

• Experience with chronic disease management (e.g., diabetes, hypertension, COPD, CHF) strongly preferred.

• Familiarity with CCM documentation requirements and workflows is a plus.
• Proficient with EHR systems and comfortable with remote communication technologies.
• Strong communication, assessment, critical thinking, and patient-engagement skills.
• Ability to work independently, manage time effectively, and maintain consistent follow-up.

Schedule & Work Environment:

• Full-time remote position (40 hours per week).
• Availability for after-hours EHR monitoring and weekend on-call support a plus.
• Work conducted from home using secure, HIPAA-compliant systems.
• Must have reliable internet connection and quiet workspace for patient calls.

Compensation & Benefits:

• Competitive pay.
• PTO, paid holidays, 401(K), various insurance programs, reimbursement for additional licenses and required CEUs.
• Opportunities for promotion and career advancement as we grow.
• Training provided on CCM requirements, EHR workflows, and documentation standards.