We are seeking experienced LPN or RN to join our growing virtual care team delivering Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) services to patients with multiple chronic conditions (diabetes, hypertension, CHF, COPD, CKD, etc.).

As a fully remote RPM/CCM Nurse, you will serve as the primary clinical point of contact for an assigned panel of 250–350 high-risk patients, providing monthly non-face-to-face care coordination, medication reconciliation, symptom monitoring, patient education, and remote physiologic data review to prevent exacerbations, reduce hospitalizations, and improve quality of life. You'll work with a team of mobile Medical Assistants and remote nurses who will assist with various aspects of patient contact, care plan management, condition management and provider facing interaction.

You'll also be responsible to monitor Labs on a daily basis for all lab submissions the previous day.

Key Responsibilities

• Conduct monthly (minimum 20-minute) CCM telephonic or secure messaging encounters, comprehensively documenting time and clinical content in the EHR to meet CMS billing requirements (CPT 99490, 99439, 99487, 99489, 99491, etc.).
• Enroll eligible patients into CCM and RPM programs, obtain verbal/written consent, and create personalized care plans in collaboration with the patient’s primary care provider.
• Review and act on daily remote physiologic monitoring data (blood pressure, blood glucose, weight, pulse oximetry, etc.) transmitted via cellular-connected devices; escalate abnormal readings according to evidence-based protocols.
• Perform medication reconciliation, identify barriers to adherence, coordinate refills, and close gaps in care.
• Facilitate transitions of care after hospitalizations or ED visits (TCM when applicable).
• Coordinate with primary care providers, specialists, home health, DME suppliers, and community resources.
• Achieve quality metrics and utilization goals (e.g., reduced 30-day readmissions, improved HbA1c, BP control, patient satisfaction).
• Maintain meticulous documentation for auditing and compliance with CMS and NCQA standards.
• Participate in daily huddles, weekly case conferences, and ongoing training.

Required Qualifications

• Active, unencumbered Nurse license in Utah.
• Compact (eNLC) or multi-state licensure strongly preferred (must be willing to obtain additional licenses if needed)
• Minimum 3 years of clinical nursing experience; case management, care coordination, or ambulatory care experience preferred.
• At least 1 year of experience in Chronic Care Management, Remote Patient Monitoring, or population health strongly preferred
• Excellent telephone and virtual communication skills; empathetic, patient-centered approach
• Proficient with EHR/EMR systems, care management platforms (e.g., ThoroughCare, ChartSpan, Optimize Health, HealthSnap, TimeDoc Health, etc.), G-Suite, and telehealth tools
• Strong organizational skills and ability to independently manage a large patient panel
• Comfortable working in a fast-paced, metric-driven environment

Preferred Qualifications

• Certified Case Manager (CCM), Ambulatory Care Nursing, or equivalent certification
• Bilingual (Spanish/English)
• Experience with Medicare regulations and billing for CCM/RPM (CPT codes, time-based documentation)
• Familiarity with value-based care models and quality measures (HEDIS, MIPS)

Technical Requirements

• Dedicated, quiet, professional home office
• High-speed internet
• Windows or Mac computer meeting company specifications

Pay: From $28.00 per hour

Work Location: Remote