Pearl Health is hiring a
Chronic Care Management Nurse in United States

Summary

The job is for a Virtual Chronic Care Manager on contract basis to manage high-risk patients eligible for chronic care management across multiple practices. The role involves providing virtual care and support, conducting assessments, educating patients about their conditions, coordinating with practice Clinical Champions, documenting patient interactions, and staying updated with developments in chronic care management.

Requirements

• Bachelor's degree in Nursing (BSN) from an accredited institution; Master's degree in Nursing (MSN) preferred
• Active Registered Nurse (RN) license in good standing
• Minimum of 2 years of clinical experience in a healthcare setting in chronic care management, preferably for Medicare beneficiaries
• Strong communication skills, both verbal and written, with the ability to engage and motivate patients virtually
• Proficiency in navigating EHRs; experience with multiple major EHRs preferred
• Ability to work independently and manage a diverse caseload efficiently
• Comfortable with technology and willing to adapt to new virtual care platforms and tools
• Strong organizational skills and attention to detail
• Ability to collaborate effectively with multidisciplinary teams and across different healthcare practices

Responsibilities

• Conduct initial and ongoing virtual assessments to capture patients' health goals
• Provide patients and their families with comprehensive education about their conditions, treatment options, and self-management strategies
• Escalate patient needs through designated Clinical Champions at Pearl’s partner practices and ensure the practice facilitates what is clinically needed by the patient and coordinates with the patient and family
• Conduct medication reconciliation with the patient. Educate patients on their prescribed medications, addressing any questions and ensuring there are no barriers to obtaining and taking their medications regularly
• Monitor patient compliance with medication regimens via check-in and document any continued chronic disease symptoms the patient is having. Escalate to Practice Clinical Champion if there may be a need for re-evaluation of med regimen
• Develop and maintain a low-friction communication channel via text message for patients and families to use in case of questions or symptom exacerbation
• Coordinate with practice’s Clinical Champion and, where appropriate, with family members to manage patient-specific needs such as appointment scheduling and follow-ups
• Document all patient interactions, care plans, and clinical updates accurately in the practice’s electronic health record (EHR) systems AND within a Pearl-designated system for performance and engagement tracking
• Ensure all care provided aligns with current best practices and regulatory requirements in chronic care management
• Engage in ongoing learning to stay abreast of developments in chronic care management and integrate new evidence-based practices into patient care