Bilingual LPN Care Coach - Bonus Eligible

LPN Care Coach Remote Position

CircleLink Health is looking for passionate, tech savvy nurses to work remotely and serve patients enrolled in Medicare's Chronic Care Management Program. In this part time role (about 20-25 hrs. per week), an LPN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital.

This Role Requires Precision, Discipline, and Accountability

The Care Manager role is not a step back from bedside nursing it's a step into a more complex, structured, and performance-driven environment. To succeed, you must bring more than clinical knowledge:

Excellent documentation skills Your charting must be complete, timely, and accurate.

Strong time management Case tasks must be prioritized and closed on schedule.

Ownership of outcomes Each case is closely tracked for quality, compliance, and effectiveness.

Expectations are high, and performance is regularly reviewed. This is not a role where details can be missed or timelines pushed we need professionals who take initiative, stay organized, and consistently deliver.

If you're ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.

Key Responsibilities:

• Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis
• Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies
• Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made
• Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc.
• Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions.
• Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.