← All jobs
What You’ll Do Annual Wellness Visit (AWV) Chart Preparation · Prepare comprehensive AWV charts to support provider efficiency and CMS compliance. · Review and summarize with patients in face-to-face virtual visits via Zoom: · Medical, surgical, and family histories · Medication lists and adherence · Preventive screenings and immunizations · Cognitive, functional, and depression assessments · Identify overdue screenings, risk factors, and care gaps prior to visits. · Communicate concise patient summaries and key findings to providers before each AWV. · Coordinate with patients to obtain missing or clarified information as needed. · Ensure documentation meets Medicare, CMS, and organizational requirements. Care Management & Clinical Oversight · Provide telephonic and portal-based care management for medically complex patients with chronic, behavioral health, and socio-economic comorbidities. · Conduct comprehensive nursing assessments addressing: · Physical, functional, psychological, social, environmental, and learning needs · Develop, implement, and monitor individualized care plans for: CCM, RPM, RTM, and APCM · Complete care plan creation and annual updates for APCM, including goal-setting, interventions, and progress tracking. · Utilize motivational interviewing to engage patients and caregivers in care planning and adherence. · Monitor patient progress, reassess goals, identify barriers, and adjust care plans as needed. · Communicate patient status and care plan updates to primary care providers and interdisciplinary care teams. · Provide patient education, coaching, and support aligned with health literacy and cultural needs. · Act as a patient advocate and assist with problem-solving and escalation when appropriate. Care Navigation & Gap Closure Actively work in care navigation to: · Identify and close care gaps (preventive screenings, labs, medications, follow-ups). · Coordinate and facilitate orders, referrals, and follow-up actions as needed. · Monitor service delivery to ensure appropriateness, avoid duplication, and meet patient needs. · Coordinate care across multiple services and providers to ensure continuity and quality. Documentation, Quality & Compliance · Maintain accurate, timely, and confidential patient records. · Utilize electronic health record systems (CT360, RXNT, Zoom) and telehealth platforms effectively. · Measure and support outcomes related to clinical quality, patient engagement, and satisfaction. · Adhere to HIPAA, CMS, and organizational compliance standards. · Participate in professional development and ongoing training. · Demonstrate strong, independent decision-making, prioritization, and multitasking skills. · Perform other duties as assigned. What We’re Looking For Required · Active, unrestricted Registered Nurse (RN) license in a compact state · Ability and willingness to obtain additional state licenses upon hire (company paid) · Minimum 3 years of clinical nursing experience to include bedside, Primary Care, Med/Surge, or Home Health experience. · Experience providing care in a telehealth or virtual care setting · Experience working remote · Experience in one or more of the following: · Chronic Care Management (CCM) · Remote Patient Monitoring (RPM) · Telehealth or virtual care coordination · Primary care or care management · Proficiency with EHR systems and telehealth platforms · Strong clinical assessment and care coordination skills · Excellent verbal and written communication skills · High level of organization, attention to detail, and time management · Ability to work independently in a remote environment · Commitment to patient-centered, culturally competent care · Dedicated, private home workspace Preferred · Experience with Medicare Annual Wellness Visits (AWVs) · Knowledge of CMS documentation and preventive care guidelines · Certification in case management or gerontological nursing · Experience working across multiple virtual care programs and platforms Work Location Requirement This is a remote U.S.-based position. Employees must perform all work physically within the United States. International work is not permitted during scheduled work hours. Work Environment This is a remote position and may be “on camera” at any time. The Registered Nurse will work from a home office, requiring reliable internet connectivity and a secure, private workspace. Technical Requirements: Computer: Windows or Apple (macOS) Computer ONLY (NO Chromebooks, Linux Machines, or Smartphones) Must have at least Windows 10 or macOS 14 Sonoma. Hardware: Processor: Intel Core i5 or AMD Equivalent (Windows); Apple Silicon (Macs) RAM: 16 GB Headphones: Wired headphones required for optimal audio quality. (NO built-in mics) Internet Speed: Meet minimum internet speed requirements (100 MBPS download speed and 50 MBPS upload speed). Must have an ethernet cable connecting computer directly into router. Browser and System: Use Google Chrome with Amazon Workspaces (regardless of computer type). Webcam: A webcam is required for video calls. Most laptops have a built-in webcam, which is acceptable. If your computer does not have a webcam, you will need to use an external webcam. Recommended Equipment: A second monitor is highly suggested for laptop users; dual monitors for PC users.
Compensation $40 / hour Listed by CareTalk Health Apply now Share this job