Chronic Care Management Nurse (CCM RN)
Location: Wilmington, DE
Job Type: Direct Hire
Company: Stoney Batter Family Medicine Associates P.A.
Salary: $58,000
Category: Non-Provider
Job Description Apply Now
The role of a Chronic Care Management Nurse (CCM RN) is essential in supporting patients with multiple chronic conditions through comprehensive care coordination and management. In this position, you will be responsible for delivering high-quality, patient-centered care outreach by managing care plans, facilitating communication between patients and healthcare providers, and ensuring all documentation is maintained accurately and efficiently. The Chronic Care Management Nurse (CCM RN) plays a critical role in enhancing patient outcomes and supporting the mission of delivering holistic healthcare services through coordinated efforts.
As a Chronic Care Management Nurse (CCM RN), you will be responsible for coordinating care management services and serving as a primary point of contact for patients enrolled in the chronic care management program. You will work closely with providers, patients, and their families to develop and implement care plans tailored to each patient's unique needs. The position requires excellent organizational skills, strong clinical judgment, and the ability to prioritize tasks in a fast-paced healthcare environment. This full-time or part-time opportunity offers a rewarding experience for nursing professionals who are passionate about making a difference in the lives of patients with complex health needs.
The Chronic Care Management Nurse (CCM RN) will be engaged in a variety of daily tasks, including identifying patient needs, coordinating interventions, maintaining meticulous documentation, and facilitating communication among healthcare team members. You will utilize various software applications and tools to track patient progress, schedule follow-up care, and identify care gaps. This role also involves providing virtual visits, patient education, and supporting colleagues during absences. Your contributions will directly support improved patient outcomes and drive clinical excellence in chronic care management.
Working as a Chronic Care Management Nurse (CCM RN) allows you to be part of a collaborative team environment that values communication, critical thinking, and a commitment to continuous improvement. You will participate in regular meetings, leverage health technology platforms to monitor patient data, and play a key role in preventing hospital readmissions by intervening proactively. If you are organized, detail-oriented, and dedicated to patient advocacy, this position provides an ideal platform to grow your nursing career while making a meaningful impact.
Chronic Care Management Nurse (CCM RN) - Summary- Coordinate and manage care for patients with multiple chronic conditions through comprehensive outreach and follow-up
- Serve as a liaison between patients, families, and healthcare providers to support personalized care plans
- Utilize electronic health records and care management software to document patient interactions accurately
- Participate in team-based care and support ongoing quality improvement initiatives
- Identify appropriate interventions based on patient needs and clinical status
- Maintain accurate documentation, including patient notes, care plans, medication reconciliation, and scheduling notes
- Coordinate closely with providers regarding patient goals, care requirements, and follow-up needs
- Share care goals with patients and families as appropriate
- Schedule and conduct follow-up calls to monitor medication changes and patient progress
- Track ongoing patient issues and document progress toward resolving problems
- Coordinate care and referrals with external offices and providers
- Assist providers with annual wellness visits by completing assessments
- Order durable medical equipment (DME) as needed
- Conduct virtual visits to support patient needs remotely
- Respond to voicemails and messages promptly throughout the day
- Support colleagues during absences with patient contact, call coverage, and messaging
- Participate in scheduled team meetings to review patient care and program improvements
- Access health technology platforms daily to monitor hospital admissions and care gaps
- Graduate or defer patients from the program as clinically appropriate
- Perform additional duties as assigned to support the care team
- Competitive compensation based on credentialing and experience
- Comprehensive health insurance coverage
- Paid time off to support work-life balance
- Flexible schedule options, including an 8-hour shift Monday through Friday
- 1-3 years of relevant experience in healthcare or care management
- Strong knowledge and competency in the healthcare services industry
- Excellent written and verbal communication skills in English
- Experience with healthcare software and hospital-based systems
- Proficiency in using various computer applications, including Microsoft Office products
- Certified Medical Assistant, Licensed Practical Nurse, or Registered Nurse credentials required
- Demonstrated organizational skills, attention to detail, and ability to multitask effectively
- Ability to work independently and as part of a collaborative team
- Organized, detail-oriented, and deadline-driven professional
- Strong multitasking ability and time management skills
- Exceptional critical thinking and problem-solving capabilities
- Demonstrated customer service mentality and patient-centered approach
- Team player with a positive attitude and willingness to support colleagues
- Adaptable to changing priorities and capable of working with minimal supervision
- Physical requirements include sitting or standing for extended periods, using computers, and lifting up to 25 lbs
- Excellent attendance and punctuality are essential for success in this role
- No travel is required for this position
- Opportunity to work in a collaborative and supportive healthcare environment
- If you are passionate about providing excellent patient care and want to contribute to a leading chronic care management program, we encourage you to apply for the Chronic Care Management Nurse (CCM RN) position by clicking the job application button