Full Job Description
CircleLink Health is in need of a registered nurse (10-20 hours per week) licensed in New York to manage patients with chronic conditions enrolled in Medicare's Chronic Care Management and Behavioral Health Integration programs.
This is a telecommute/work from home position.
Candidates do not have to reside in New York, but must have an RN license to practice in New York.
Job Type: Contract
Hourly Pay Rate (Efficiency-based)
Educate patient on self-management skills and goal setting. These are patients with chronic conditions such as: Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, Depression.
Implement and update the Plan of Care. Update medications, appointments due, record biometrics, vital signs, and care coaching provided.
Utilize Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management.
Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions, i.e. medication reconciliation, medication adherence, identify red flags, address barriers, encourage follow-up care, how and when to seek appropriate level of care.
Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
Connect the patient with community resources as needed, i.e. transportation, personal care needs, homemaker or chore services, social services, etc.
Current, unrestricted RN license in the state of New York
Proficiency with electronic health records and web based applications
Must be self-directed, able to work independently with little supervision while meeting performance metrics
Excellent organizational and time management skills
Strong telephonic skills
Strong critical thinking and problem solving skills
Case Management or Chronic Disease Management experience
Case Management Certification
Certified Diabetes Educator
Transitional Care Management experience
Experience with Motivational Interviewing or other behavior change communication techniques
Bilingual in Spanish and English is a plus
About CircleLink Health
CircleLink is a digital healthcare company that improves health for the chronically ill by engaging patients through personal phone calls and/or mobile technology, helping to solve the ~$600 billion problem of preventable chronic complications.
Our patient engagement software and services enable physicians to monitor and manage their patients' chronic conditions between office visits without investing in additional staff or technology.
We offer a fun team and the chance to significantly contribute to products already used by patients and doctors at top institutions (e.g., Johns Hopkins, Yale-New Haven Hospital, Emory and Tulane Medical Center).