RN Chronic Care Manager (Contract) – Telehealth

CareTalk Health is a physician-owned medical practice with licensed doctors and registered nurses serving patients across all 50 states and the District of Columbia. We specialize in providing longitudinal care services such as Chronic Care Management, Remote Patient Monitoring, and Remote Therapeutic Monitoring. As a CareTalk Health team member, you’ll be working to provide virtual care to our client’s patients. CareTalk Health is committed to providing high-quality, affordable, and accessible healthcare to all patients. If you’re a healthcare professional passionate about providing patients with high-quality care, CareTalk Health is a great place to work.

We are excited to invite a skilled Registered Nurse with expertise in Chronic Care Management (CCM) to join our innovative Telehealth Services team. This contract role offers the flexibility of being 100% remote, allowing you to work from any state across the nation. In this position, you will work up to 40 hours per week, Monday through Friday, with 8-hour shifts that may vary between 8:00 AM and 10:00 PM EST. Additionally, opportunities may arise for weekend and holiday shifts. As a valued member of our team, you will receive competitive hourly compensation of $35.00 for clinical services. Your responsibilities will encompass the development and oversight of comprehensive care plans for Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), and any other relevant services within your professional scope. Under the guidance of the Clinical Team Leader, you will play a crucial role in the intake and care management of medically complex patients. This patient population may include individuals with significant medical conditions, as well as social, economic, and mental health co-morbidities. Our program’s mission is to empower these patients to achieve optimal health and foster independence in managing their care. In this dynamic role, you will leverage your expertise to apply the principles of Chronic care management and provide compassionate, patient-centered, and culturally sensitive care coordination. Your responsibilities may include: Developing tailored care plans that encompass comprehensive motivational assessments and strategies for encouraging patient engagement and adherence. Conducting thorough nursing assessments and closely monitoring patient and family care plans, including considerations for end-of-life planning where appropriate. Serving as the primary contact for patients, families, and other involved healthcare providers, facilitating effective communication primarily through phone interactions.

Assess the physical, functional, social, psychological, environmental, and learning needs of patients. Identify problems, goals and interventions designed to meet patient’s needs, including prioritized goals that consider the patient/caregivers goals, preferences, and desired level of involvement in the care management plan. Create care plans including objectives, goals and actions designed to meet patient’s needs. Provide appropriate interventions, which demonstrate knowledge of the sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services as needed. Assess the patient’s formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources. Implement and monitor the care plan to ensure the effectiveness and appropriateness of services. Evaluate patient’s progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with care management plan of care, and systematically reassess for changes in goals and/or health status. Communicates with primary care physician and members of the comprehensive care team regarding the status of patient as needed or requested by patient. Utilize motivational interviewing skills to build patient engagement in the development of the plan of care. Provide education, information, direction, and support related to care goals of patients. Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Maintain accurate patient records and patient confidentiality. Measure outcomes and effectiveness of care management including clinical, quality of life and patient/family satisfaction. Engage in professional development activities to keep abreast of care management practices and patients’ engagement strategies. Use of Electronic Record and utilizes technology as appropriate to meet the requirements of the job functions. Must have the ability to make critical independent decisions and prioritize appropriately. must be detail oriented and able to multitask. Displays an exemplary level of patience, courtesy, and flexibility. Performs other duties as assigned.