Registered Nurse – Care Management
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Job Description
Registered Nurse managing complex patients, virtual care plans, and Annual Wellness Visit preparation. CareTalk Health delivers scalable telehealth and clinical process outsourcing services.
Responsibilities:
- Prepare comprehensive Annual Wellness Visit charts supporting provider efficiency and CMS compliance
- Review medical, surgical, and family histories; medication lists and adherence; preventive screenings and immunizations; cognitive, functional, and depression assessments with patients during virtual Zoom visits
- Identify overdue screenings, risk factors, and care gaps before visits
- Communicate patient summaries and key findings to providers
- Obtain missing or clarified patient information
- Ensure documentation meets Medicare, CMS, and organizational requirements
- Provide telephonic and portal-based care management for medically complex patients with chronic, behavioral health, and socio-economic comorbidities
- Conduct comprehensive nursing assessments covering physical, functional, psychological, social, environmental, and learning needs
- Develop, implement, and monitor individualized CCM, RPM, RTM, and APCM care plans
- Complete APCM care plan creation and annual updates
- Use motivational interviewing to engage patients and caregivers
- Monitor progress, reassess goals, identify barriers, and adjust care plans
- Communicate patient status and care plan updates to providers and interdisciplinary teams
- Provide patient education, coaching, and culturally appropriate support
- Advocate for patients and assist with problem-solving and escalation
- Identify and close preventive, laboratory, medication, and follow-up care gaps
- Coordinate orders, referrals, follow-up actions, and care across services and providers
- Monitor service delivery for appropriateness, continuity, and quality
- Maintain accurate, timely, and confidential patient records
- Use CT360, RXNT, Zoom, EHR systems, and telehealth platforms
- Support clinical quality, patient engagement, and satisfaction outcomes
- Adhere to HIPAA, CMS, and organizational compliance standards
- Participate in professional development and ongoing training
- Make independent decisions, prioritize, multitask, and perform other assigned duties
Requirements:
- Active, unrestricted Registered Nurse (RN) license in a compact state
- Ability and willingness to obtain additional state licenses upon hire
- Minimum 3 years of clinical nursing experience, including bedside, Primary Care, Med/Surge, or Home Health experience
- Experience providing care in a telehealth or virtual care setting
- Remote work experience
- Experience with CCM, 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 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
- Employees must perform all work physically within the United States; international work is not permitted during scheduled work hours
- Windows or Apple macOS computer only; no Chromebooks, Linux machines, or smartphones
- Windows 10 or macOS 14 Sonoma minimum
- Intel Core i5 or AMD-equivalent processor on Windows, or Apple Silicon on Mac
- 16 GB RAM
- Wired headphones without built-in microphones
- Internet speed of at least 100 Mbps download and 50 Mbps upload
- Ethernet cable directly connecting the computer to the router
- Google Chrome with Amazon Workspaces
- Webcam required for video calls
- Preferred: Medicare Annual Wellness Visit experience, CMS documentation and preventive care knowledge, case management or gerontological nursing certification, and experience across multiple virtual care programs and platforms
Benefits:
- Ability to obtain additional state licenses upon hire (company paid)
- Professional development and ongoing training
- Company-paid additional state licenses
- Remote work from a home office
- Equal opportunity and inclusive work environment
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