Registered Nurse – Chronic Care Management

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🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Oak Medical, SC

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

Healthcare

Oak Medical is an onsite physician services company that provides coordinated, patient-centric medical care for post-acute environments, specialty hospitals, skilled nursing facilities, and senior living communities. Their team includes internal medicine physicians, advanced practice providers, nurse practitioners, and specialty providers delivering services such as internal medicine with geriatric focus, wound care, psychiatry (psychiatric mental health nurse practitioners), palliative care, telemedicine, and comprehensive RN-led care management to reduce readmissions and improve quality of life. Oak Medical emphasizes provider engagement, care team integration, and bringing medical services directly to assisted, independent, and memory care facilities across Wisconsin.

📋 Description

• Provide clinical triage by responding to calls, electronic messages, and health concerns from patients, families, facility staff, and care partners • Use clinical judgment and assessment skills to determine the appropriate level of care, from routine follow-up and education to provider notification or urgent escalation • Conduct telephonic, electronic, and occasional in-person assessments related to symptoms, changes in condition, chronic conditions, medications, and other health concerns • Develop and maintain individualized care plans with patients, families, facility staff, providers, and the healthcare team • Coordinate referrals, medication questions, lab and order clarification, DME needs, prior authorizations, follow-up care, and other patient needs • Provide education and reassurance regarding chronic disease management, medications, preventive care, symptom monitoring, and when to seek additional medical attention • Monitor patient needs and follow-up plans, ensuring recommendations and provider-directed interventions are completed timely • Document clinical encounters, assessments, interventions, care coordination, and follow-up according to protocols and regulatory requirements • Support Medicare Part B Chronic Care Management services and documentation requirements • Collaborate with a multidisciplinary team to improve the quality and coordination of patient care

🎯 Requirements

• Current, unrestricted Wisconsin RN license • Strong clinical assessment and critical thinking skills • Excellent communication and interpersonal skills • Ability to manage multiple priorities and respond appropriately to time-sensitive clinical concerns • Ability to work independently while collaborating effectively with a multidisciplinary team • Knowledge of geriatric care and the unique healthcare needs of seniors • Familiarity with electronic health records • BSN preferred • Certification in Gerontology or Chronic Care Management (CCM) preferred • Experience in triage, senior living, long-term care, care coordination, or a similar nursing role preferred • Experience with Medicare Part B Chronic Care Management programs or CMS quality reporting preferred

🏖️ Benefits

• Remote work environment • Monday–Friday schedule • Meaningful work supporting the health and well-being of seniors • Collaboration with an experienced multidisciplinary healthcare team • Opportunities to grow your knowledge of chronic care management and care coordination • 401(k) with employer contribution • Medical, Dental & Vision Insurance • Employer-paid Life Insurance