The Registered Nurse (RN) or Licensed Practical Nurse (LPN) supports the Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) Programs by providing ongoing care coordination, patient outreach, documentation, medication reconciliation, and communication with patients, caregivers, providers, pharmacies, specialists, hospitals, and community resources. The nurse assists in ensuring patients with chronic conditions receive comprehensive, coordinated care while supporting program compliance, quality outcomes, and reimbursement goals.

1. Chronic Care Management Activities

• Document all CCM/APCM activities in the Electronic Medical Record (EMR) in accordance with CMS guidelines.
• Accurately track and record CCM time.
• Assist in identifying patients eligible for CCM/APCM enrollment.
• Review prior CCM/APCM documentation to ensure continuity of care and avoid duplication of services.
• Assist with annual and interim updates of individualized patient care plans.

2. Care Coordination

• Provide support for patients transitioning from hospitalizations or other acute settings.
• Ensure all APCM/CCM patients have a personalized care plan that addresses their unique needs, preferences, and goals, including medication management, health education, lifestyle modifications and specialist coordination.
• Follow up on referrals, diagnostic testing, and specialty consultations.

3. Clinical Review and Documentation

• Review medical records for gaps in care and preventative health needs.
• Reconcile medications utilizing Medication Administration Records (MARs), and provider documentation.
• Update problem lists, diagnoses, allergies, immunizations, and patient demographic information as appropriate.
• Assist with documentation required for quality measures and value-based care initiatives.

4. Quality and Compliance

• Participate in audits and quality improvement initiatives. Monitor and evaluate the effectiveness of the APCM/CCM program, using data and metrics to assess progress toward goals. 
• Ensure that all work performed under the APCM/CCM program is meaningful, high-quality and compliant with relevant regulations and standards.

5. Collaboration and Creativity

• Work collaboratively with providers, medical assistants, patient representatives, nursing staff, and administrative personnel.
• Applies critical thinking and creativity to develop innovative approaches to care management.
• Foster a patient-centered culture that prioritizes quality, compassion, and continuous improvement.
• Assist the CCM Coordinator in achieving monthly program goals and improving patient outcomes.
• General
• Provides care in a non-judgmental, non-discriminatory manner that is sensitive to the patient’s and family’s diversity, preserving their autonomy, dignity and rights.
• Completes assignments as requested by supervisor.

• Graduation from an accredited Bachelor of Science in Nursing (BSN) program and an active Registered Nurse (RN) license, required; or
• High school diploma or equivalent (GED) and graduation from an accredited Licensed Practical Nurse (LPN) program, required.
• Excellent verbal and written communication skills-Strong organizational skills
• Strong documentation and computer skills.
• Strong Commitment to the provision of quality medical care for medically underserved individuals.
• Ability to work independently while managing multiple priorities.
• Proven capacity to work productively in highly collaborative settings and to seek and synthesize input from multiple stakeholders.
• Minimum one year of nursing experience preferred
• Experience working with individuals with Intellectual and Developmental Disabilities (I/DD), including coordination of medical, behavioral health, residential, and community-based services, strongly preferred.
• Experience in primary care, case management, care coordination, population health, or chronic disease management preferred.
• Knowledge of Electronic Medical Records (EMR) systems.

Preferred Skills

• Strong oral, written, and organizational skills required.
• Prior experience coordinating medical record activities of a busy medical office or healthcare center, a plusPhysical Requirements

Physical Requirement

• Prolonged periods of sitting and computer work.
• Monday through Friday, as assigned. Flexibility to work in both health centers as assigned.  Role can be done as hybrid, in-person, remote basis on needs of health center. 

Salary Ranges:

• License Practical Nurse: $66,300,000-$70,000
• Register Nurse RN: $75,000-$80,000