CCM Registered Nurse Coordinator - Hybrid​/Durham

CCM Registered Nurse Intake Coordinator - Hybrid

Join our Chronic Care Management (CCM) team within Avance Care
, a leading network of 37 practice locations across the Triangle Area (Raleigh-Durham-Chapel Hill), the Charlotte Region, and Wilmington, NC. Avance Care is dedicated to elevating the standard of healthcare. As one of North Carolina's largest networks of independent primary care practices, we provide comprehensive, patient-centered services that support the physical, mental, and emotional well-being of our patients.

We are recruiting for a Registered Nurse (RN) to join our Chronic Care Management (CCM) team. This hybrid role is based at our headquarters in Durham, combining in‑office and remote work for a balanced schedule. The CCM RN Coordinator will establish, implement, monitor, and evaluate high‑quality, cost‑effective care plans as patients transition across the care continuum. You will work in a supportive and collaborative environment that values your contributions and offers opportunities for professional growth.

Comprehensive benefits are available starting the first of the month following 30 days of employment.

• Review patients’ medical and social health status using electronic medical records, claims data, and community resources.
• Conduct outreach to confirm diagnoses, contributing factors, anticipated treatment plans, and barriers to care.
• Facilitate access to necessary care by navigating barriers, advocating for patients, and educating families/caregivers.
• Monitor patients enrolled in care management to ensure treatment goals are met and shared across care teams.
• Track and support patients post‑hospitalization or ER visits to ensure continuity of care and reduce readmission risks.
• Assist in primary care provider triage assessment and direct patients to appropriate services.
• Provide clinical supervision for LPNs, MAs, and CNAs in case conferencing and approve care plans.
• Coordinate patient case assignments based on the clinical abilities of paraprofessional staff.
• Maintain accurate documentation in the electronic medical record and communicate updates to care teams.
• Identify workflow improvements to enhance cost‑effective, high‑quality care delivery.
• Stay updated on healthcare regulations, trends in ambulatory and cross‑continuum care, and accountable care organizations.
• Utilize information technology to identify high‑risk patients and address care gaps.
• Develop and maintain relationships with internal and external stakeholders.

• Related degree: ADN or BSN.
• Active Registered Nursing license.
• At least 3 years of direct patient care experience.
• Preferred: experience in case management, home health nursing, health coaching/education, medication administration, or geriatric care.

• Strong verbal and written communication.
• Ability to maintain confidentiality and integrity.
• Growth mindset.
• Flexibility and resilience.
• Knowledge of common medical terminology and HIPAA regulations.
• Ability to work collaboratively in a team‑oriented environment.

All offers of employment are contingent upon the successful completion of a background check and drug screen.

Avance Care provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, gender identification, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.