Chronic Care Management Nurse (Hybrid)

Job Title: Remote Chronic Care Management (CCM) Nurse (Hybrid) Department: Nursing Reports To: Director of Care Management Programs Employment Classification: Remote | Clinical Role Position Summary The Remote Chronic Care Management (CCM) Nurse is responsible for delivering CMS-compliant chronic care management services to eligible patients with multiple chronic conditions. This role emphasizes longitudinal care coordination, collaboration with facility staff and providers, development and maintenance of individualized care plans, quality measure tracking, and transition‑of‑care support. The CCM Nurse ensures services are delivered in compliance with CMS regulations governing CCM, institutional care settings, and billing restrictions during covered SNF stays. The CCM Nurse also supports Annual Wellness Visit (AWV) preparation and scheduling when patients are eligible and not otherwise restricted by institutional status. Essential Functions and Responsibilities Chronic Care Management Identify and manage patients eligible for CCM services under CMS guidelines. Verify patient care setting (NF, or covered SNF stay) to ensure CCM services are initiated, paused, or resumed appropriately. Coordinate with Clinical Support Team (CST) members to obtain, document, and track CCM patient consent, including outreach to Power of Attorney (POA) or legally responsible parties when applicable. Provide and document a minimum of 20 minutes of non‑face‑to‑face CCM services per patient per month when CMS eligibility criteria are met. Suspend CCM billing activities during covered SNF Part A stays and resume services following discharge or loss of skilled coverage, per CMS rules. Conduct periodic outreach to patients, responsible parties, and/or facility‑designated contacts as appropriate. Provide and document monthly care plan reviews and updates when CCM services are active. Care Plan Development and Maintenance Develop, implement, and maintain comprehensive, patient-centered care plans reflective of patients’ chronic conditions, functional status, and institutional care environment. Ensure care plans address: - Medical and chronic condition management - Functional status and ADLs - Behavioral health needs - Psychosocial and caregiver considerations - Coordinate care plan alignment with facility care plans while maintaining the provider‑directed CCM plan of care. Update care plans based on changes in patient condition, treatment goals, or provider recommendations. Ensure care plans are accessible to appropriate members of the care team. Care Coordination and Clinical Collaboration Collaborate with primary care providers, specialists, Care Support Team (CST) members, SNF/NF nursing and administrative staff and other healthcare professionals. Make clinical recommendations to providers to support optimal chronic disease management. Including: recommending referrals, appointments, lab work, diagnostic testing, and follow-ups. Monitor for gaps in care following discharge from skilled services and support re‑engagement in CCM when eligible. Annual Wellness Visit (AWV) Support Identify patients eligible for Annual Wellness Visits, considering institutional status and CMS eligibility criteria. Support AWV preparation by scheduling with provider and collecting health history, screening data, and preventive care measures prior to AWVs. Coordinate with CST members. Quality Measures and Performance Tracking Track and support quality measures, preventive screenings, and care gap closures. Support quality initiatives related to chronic disease management, readmission reduction, and value‑based care programs. Support organizational quality improvement and value-based care programs. Documentation and Systems Use Accurately document all care coordination activities, CCM time, consent status, care plans, and eligibility determinations in the EHR. Utilize CCM tracking tools, population health platforms, and telecommunication systems. Maintain full compliance with HIPAA, facility communication protocols, and organizational data security policies. Required Qualifications Education and Licensure Active, unrestricted Licensed Practical Nurse license Compact license preferred for multi‑state practice Experience Minimum of 2 years of clinical nursing experience Experience in one or more of the following preferred: Skilled Nursing Facility (SNF), Nursing Facility (NF), or Post‑acute or long‑term care Care coordination or case management Chronic disease management Population health or value‑based care Experience with Medicare patients and/or CCM programs Required Knowledge, Skills, and Abilities Strong clinical assessment and critical thinking skills Knowledge of CMS regulations related to: - Chronic Care Management - SNF Part A coverage Excellent organizational skills and attention to detail Effective verbal and written communication skills Ability to work independently in a remote environment Ability to collaborate with facility staff and external providers Ability to manage multiple patient populations and priorities Proficiency with EHR systems and healthcare technology platforms Knowledge of CMS, Medicare, and CCM documentation requirements Ability to maintain strict confidentiality and professional boundaries Physical and Work Environment Requirements Prolonged periods of sitting while working at a computer Frequent telephone and virtual communications Reliable high‑speed internet access Ability to work standard business hours with flexibility based on patient and operational needs Performance Expectations Compliance with CMS CCM and AWV program requirements Accurate identification and documentation of SNF/NF eligibility status Timely and accurate documentation and time tracking Meeting monthly CCM patient engagement and quality goals Adherence to organizational policies, procedures, and compliance standards #J-18808-Ljbffr Vitora Healthcare