Registered Nurse Care Coach

About the role

CircleLink Health is seeking a passionate, tech-savvy Registered Nurse to work remotely and support patients enrolled in Medicare's Chronic Care Management Program.

Responsibilities

• Utilize 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, 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.

Requirements

• Fluent in English
• Self-directed, able to work independently with little supervision while meeting performance metrics
• Passion for nursing and improving patient outcomes
• Good with technology and eager to learn and use new software
• Excellent organizational and time management skills
• Timely communication is essential, and nurses are expected to respond to all messages and emails within 24-48 hours
• Strong critical thinking and problem-solving skills

Education and Experience

• Current, unrestricted Compact License / multistate RN license
• Proficiency with electronic health records and web-based applications
• 3+ years' experience as a Registered Nurse
• Preferred: Case Management or Chronic Disease Management experience, Certified Diabetes Educator, experience with Motivational Interviewing or other behavior change communication techniques

Scheduling and Other Requirements

• RN needs a STRONG internet-connected computer
• Minimum of 20 hours of availability per week required
• You will commit to your own schedule using our software
• This is a 1099 contract position with no end date
• Care coaches are responsible for their own taxes and insurance