Physician Assistant (PA-C)/ Nurse Practitioner (NP), San Bernardino

Join Our Team as a Remote Chronic Care Management Specialist

We are looking for a compassionate and skilled Physician Assistant (PA-C) or Nurse Practitioner (NP) to join our team in supporting patients through our Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. This role emphasizes proactive, patient-centered care—leveraging advanced clinical expertise to help individuals better manage chronic conditions, reduce risks, and improve overall health outcomes.

You will be responsible for conducting detailed clinical assessments, creating and adjusting care plans, delivering patient education, and collaborating closely with an interdisciplinary care team.

Primary Responsibilities

Patient Assessments & Clinical Care

• Conduct in-depth medical, psychosocial, and risk evaluations.
• Diagnose, manage, and monitor chronic conditions according to current best practices.

Care Planning & Management

• Design and implement customized care plans that reflect patient needs and goals.
• Partner with physicians, pharmacists, and care coordinators to deliver seamless care.

Patient Engagement & Education

• Provide guidance on disease management, medications, prevention, and lifestyle changes.
• Apply motivational interviewing and coaching methods to encourage adherence and long-term health improvements.

Clinical Oversight & Coordination

• Ensure timely communication with patients, caregivers, and providers.
• Track diagnostic results, monitor treatment progress, and take action to prevent avoidable complications.

Data-Driven Interventions

• Review RPM data for early signs of concern and intervene as needed.
• Use analytics and population health tools to support proactive outreach.

Documentation & Compliance

• Maintain accurate, timely clinical records within the EHR.
• Adhere to CMS and regulatory standards for CCM and RPM documentation.

Program Leadership Support

• Assist with patient enrollment into care programs.
• Contribute to ongoing program evaluation, performance improvement, and patient satisfaction efforts.

Qualifications

Education & Licensure

• Active, unrestricted California PA-C or NP license.
• National certification required (NCCPA for PAs; AANP or ANCC for NPs).

Professional Experience

• At least 2 years of direct clinical experience in primary care, internal medicine, geriatrics, or chronic disease management.
• Prior involvement in CCM, RPM, or value-based care initiatives is strongly preferred.

Technical Proficiency

• Skilled in EHR documentation and workflow.
• Familiarity with RPM devices, telehealth platforms, and digital health tools is a plus.

Core Skills

• Strong clinical judgment and decision-making capabilities.
• Excellent communication skills for patient counseling and team collaboration.
• Organized, self-motivated, and able to balance multiple priorities in a remote environment.

Work Environment

• Must maintain a HIPAA-compliant, private workspace with reliable internet for telehealth-based care.