Transitional Care and Chronic Care Nurse Practitioner

Job Title:

Remote Nurse Practitioner – Chronic Care Management (CCM) and Transitional Care Management (TCM)

Location:

Fully Remote (U.S.

-based; must be licensed in multiple states or hold a compact license preferred)

Job Type: Full-Time (Flexible scheduling available)

We are a forward-thinking telehealth organization dedicated to improving outcomes for patients with chronic conditions through innovative care management programs. Our team supports Medicare beneficiaries and others with multiple chronic illnesses by delivering high-quality, patient-centered care remotely. Join us in making a meaningful impact on patient lives while enjoying the flexibility of remote work.

We are seeking an experienced Nurse Practitioner to provide remote Chronic Care Management (CCM) and Transitional Care Management (TCM) services. In this role, you will manage care for patients with two or more chronic conditions, facilitate smooth transitions post-hospitalization or facility discharge, and promote self-management to reduce readmissions and improve health outcomes. This is a 100% remote position utilizing telehealth platforms for patient interactions.

• Develop, implement, revise, and monitor comprehensive, patient-centered care plans for CCM patients.
• Conduct regular non-face-to-face care management (e.g., monthly check-ins via phone or video) to assess health status, medication adherence, and progress toward goals.
• Provide Transitional Care Management services, including timely contact post-discharge (within 2-7 days), medication reconciliation, and coordination of follow-up care to prevent readmissions.
• Educate patients and caregivers on disease self-management, symptom recognition, and lifestyle modifications.
• Coordinate care with primary care providers, specialists, pharmacists, and community resources.
• Document all services thoroughly in the electronic health record (EHR) to ensure compliance with Medicare billing requirements.
• Manage acute changes in condition remotely, escalating as needed while providing 24/7 access support (shared team coverage).
• Collaborate with an interdisciplinary team to enhance care continuity and patient engagement.

• Master's or Doctoral degree in Nursing from an accredited program.
• Current, unrestricted Nurse Practitioner license (APRN) with national board certification (FNP, AGNP, or Adult/Gerontology preferred).
• Active licensure in at least 3-5 states (multi-state compact license strongly preferred for broader patient reach).
• Minimum of 2-3 years of clinical experience as a Nurse Practitioner, with preference for backgrounds in primary care, geriatrics, case management, or chronic disease management.
• Experience with Medicare CCM and/or TCM programs highly desirable.
• Proficiency in telehealth platforms, EHR systems, and remote patient monitoring tools.
• Strong clinical assessment, decision-making, and communication skills.
• Ability to work independently in a remote environment with reliable high-speed internet and a private, HIPAA-compliant workspace.

• Compassionate, patient-centered approach with excellent motivational coaching abilities.
• Knowledge of evidence-based guidelines for managing common chronic conditions (e.g., diabetes, hypertension, heart failure, COPD).
• Commitment to compliance with CMS regulations for CCM/TCM billing and documentation.
• Tech-savvy with the ability to troubleshoot basic virtual visit issues.

• Competitive salary (commensurate with experience) + performance incentives.
• Flexible scheduling to support work-life balance.
• Paid time off, holidays, and continuing education opportunities.
• Professional development and licensure reimbursement support.

We are an equal opportunity employer and value diversity in our team.

Join our team and help transform chronic and transitional care—one patient at a time—from the comfort of your home!