Benefits:
Competitive salary
Flexible schedule
Opportunity for advancement
About Us:
We are a growing home care agency expanding our Chronic Care Management (CCM) and care coordination services to better support patients with multiple chronic conditions. Our mission is to improve outcomes, reduce hospitalizations, and provide proactive, patient-centered care in collaboration with caregivers, families, and providers.
Position Summary:
We are seeking a Nurse Practitioner (NP) to lead and support our Chronic Care Management program. This role focuses on care coordination, clinical oversight, patient education, and interdisciplinary collaboration for patients with two or more chronic conditions. The ideal candidate is organized, compassionate, and experienced in managing complex patients outside of traditional office visits.
Key Responsibilities
Conduct comprehensive CCM assessments and ongoing monthly care management
Develop, implement, and update individualized care plans
Monitor chronic conditions (e.g., CHF, COPD, diabetes, hypertension, dementia)
Coordinate care with physicians, specialists, caregivers, and community resources
Provide patient and family education and support via phone or telehealth
Identify gaps in care and intervene proactively to prevent hospitalizations
Document CCM activities accurately in accordance with Medicare guidelines
Support compliance with CMS CCM requirements and quality measures
Collaborate with agency leadership to grow and enhance the care management program
Qualifications
Active Nurse Practitioner license (state-specific)
National NP certification (AANP or ANCC)
Minimum 2 years of clinical experience (primary care, geriatrics, home care, or care management preferred)
Experience with chronic disease management and care coordination
Familiarity with Medicare CCM services and documentation requirements (preferred)
Strong communication, organization, and time-management skills
Comfortable working independently in a remote or hybrid environment
EMR experience required
What We Offer
Competitive compensation
Flexible schedule (ideal for work-life balance)
Opportunity to help build and shape a growing CCM program
Collaborative, mission-driven work environment
Supportive leadership and administrative support
Flexible work from home options available.