Project overview
About the Role We are seeking a dedicated Licensed Nurse (LPN / RN) to build meaningful patient relationships, elevate patient care, and deliver excellent healthcare services in a fully virtual environment. This is an exciting opportunity to grow our clinical care team in the Appalachian region and will be pivotal in providing comprehensive care solutions for patients in West Virginia with chronic conditions such as cardiovascular disease, diabetes, obesity, and respiratory challenges. You will manage patients’ healthcare needs through remote monitoring and communication, develop personalized care plans, coach patients on treatments, and connect with patients and their care teams regarding resources, appointments, etc. This position is fully remote, offering flexibility while maintaining high standards of patient care. If youre passionate about making a lasting impact through connected, compassionate care while contributing to a rapidly growing and innovative organization, we’d love to speak with you. You’ll join a mission-driven team that’s redefining how care is delivered for patients with chronic conditions. Rooted in values of respect, accountability, innovation, and unity, we are committed to being a lifelong partner in patient health - delivering care that goes beyond the clinic. What we are: compassionate, missional, ethical, innovative, and patient-centered What we are not: stagnant, unreasonable, self first, lacking purpose Logistics: Location: Remote (100%) Resides: Ideally in WV or Appalachian region Travel: 0% Key Responsibilities Patient Engagement & Care Coordination: Conduct monthly outreach calls to assigned patients, ensuring continuity of care. Develop and update individualized CCM care plans based on patient assessments. Collaborate with interdisciplinary teams, including physicians, nurses, and social workers, to optimize patient care. Provide health education and self-management strategies tailored to chronic conditions. Address social determinants of health impacting patient care in rural communities. Clinical Documentation & Compliance: Maintain accurate and timely documentation in the Electronic Health Record (EHR) system. Ensure compliance with CMS guidelines for Chronic Care Management services. Adhere to HIPAA regulations to protect patient confidentiality. Follow NCQA and Joint Commission standards for care coordination. Patient Advocacy & Support: Identify barriers to care and assist patients in accessing necessary healthcare resources. Monitor patient progress and escalate concerns to the appropriate healthcare providers. Promote culturally competent care, recognizing the unique healthcare challenges in Appalachia. Additional Responsibilities: This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities, as necessary. Qualifications/Requirements Licensure: Active Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in a Compact State or one of the following states: West Virginia, Pennsylvania, Ohio, Kentucky, Virginia, Tennessee, North Carolina, South Carolina, Georgia, Alabama, or Mississippi. Experience: Minimum 2 years of clinical experience, preferably in chronic care management, telehealth, or primary care. Preferred 5+ years experience as a LPN. Technical Skills: Proficiency in EHR systems, telehealth platforms, and remote patient monitoring tools. Communication Skills: Strong ability to engage patients via phone and digital platforms wit ... (Description has been truncated due to length limits)