CircleLink Health is looking for a remote LPN Care Coach to join our team of clinicians and technologists tackling preventable chronic condition complications. You will work 20-25 hours per week managing patients enrolled in Medicare’s Chronic Care Management program, using coaching and education to improve health outcomes.
What You'll Do
- Educate patients on self-management skills and goal setting for chronic conditions such as Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, and Depression.
- Implement and improve the Plan of Care by updating medications, appointments due, recording biometrics and vital signs, and documenting care coaching provided.
- Utilize Motivational Interviewing or other behavior change techniques to coach and assist patients with self-management.
- Conduct Transitional Care Management activities for high-risk patients discharged from the hospital or ER to reduce unnecessary readmissions.
- Reduce care gaps by encouraging or assisting with preventive care and chronic care management.
- Connect patients with community resources as needed, including transportation, personal care needs, homemaker or chore services, and social services.
What We're Looking For
- Fluent in English with strong communication skills.
- Self-directed, able to work independently with little supervision while meeting performance metrics for case completion.
- Strong passion for nursing of Medicare patients.
- Commitment to acknowledge and respond to all messages and emails from staff within 24–48 hours.
- Ability to manage a caseload of at least 40 patients.
- Excellent organizational, time management, critical thinking, and problem-solving skills.
- Commitment to work 20-25 hours, 3 days a week with availability to make calls between 9-6 pm EST.
- Current, unrestricted Compact LPN license.
- Proficiency with electronic health records and web-based applications.
- At least 5+ years' experience as a Licensed Practical Nurse.
- Access to a strong internet-connected computer (company does not provide).
Nice to Have
- 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.
Work Mode
This is a fully remote position. You will work from your own home office.
CircleLink Health is an equal opportunity employer.
