Chronic Care Management Nurse; Hybrid

Job Title:
Remote Chronic Care Management (CCM) Nurse (Hybrid)

Department: Nursing

Reports To: Director of Care Management Programs

Employment Classification: Remote | Clinical Role

The Remote Chronic Care Management (CCM) Nurse is responsible for delivering CMS-compliant chronic care management services to eligible patients with multiple chronic conditions. This role emphasizes longitudinal care coordination, collaboration with facility staff and providers, development and maintenance of individualized care plans, quality measure tracking, and transition‑of‑care support. The CCM Nurse ensures services are delivered in compliance with CMS regulations governing CCM, institutional care settings, and billing restrictions during covered SNF stays.

The CCM Nurse also supports Annual Wellness Visit (AWV) preparation and scheduling when patients are eligible and not otherwise restricted by institutional status.

• Identify and manage patients eligible for CCM services under CMS guidelines.
• Verify patient care setting (NF, or covered SNF stay) to ensure CCM services are initiated, paused, or resumed appropriately.
• Coordinate with Clinical Support Team (CST) members to obtain, document, and track CCM patient consent, including outreach to Power of Attorney (POA) or legally responsible parties when applicable.
• Provide and document a minimum of 20 minutes of non‑face‑to‑face CCM services per patient per month when CMS eligibility criteria are met.
• Suspend CCM billing activities during covered SNF Part A stays and resume services following discharge or loss of skilled coverage, per CMS rules.
• Conduct periodic outreach to patients, responsible parties, and/or facility‑designated contacts as appropriate.
• Provide and document monthly care plan reviews and updates when CCM services are active.

• Develop, implement, and maintain comprehensive, patient-centered care plans reflective of patients’ chronic conditions, functional status, and institutional care environment.
• Ensure care plans address:
  
  - Medical and chronic condition management
  - Functional status and ADLs
  - Behavioral health needs
  - Psychosocial and caregiver considerations
  - Coordinate care plan alignment with facility care plans while maintaining the provider‑directed CCM plan of care.
• Update care plans based on changes in patient condition, treatment goals, or provider recommendations.
• Ensure care plans are accessible to appropriate members of the care team.

• Collaborate with primary care providers, specialists, Care Support Team (CST) members, SNF/NF nursing and administrative staff and other healthcare professionals.
• Make clinical recommendations to providers to support optimal chronic disease management. Including: recommending referrals, appointments, lab work, diagnostic testing, and follow-ups.
• Monitor for gaps in care following discharge from skilled services and support re‑engagement in CCM when eligible.

• Identify patients eligible for Annual Wellness Visits, considering institutional status and CMS eligibility criteria.
• Support AWV preparation by scheduling with provider and collecting health history, screening data, and preventive care measures prior to AWVs.
• Coordinate with CST members.

• Track and support quality measures, preventive screenings, and care gap closures.
• Support quality initiatives related to chronic disease management, readmission reduction, and value‑based care programs.
• Support organizational quality improvement and value-based care programs.

• Accurately document all care…