Chronic Care Nurse

About the role

The Chronic Care Nurse provides chronic care and clinical case management services to enhance patient‑centered care across the care continuum. This role involves assessing patient needs, coordinating resources, and implementing disease‑modifying interventions from admission through discharge and follow‑up.

Key responsibilities

• Maintain confidentiality in accordance with HIPAA and Evergreen Family Medicine policies.
• Coordinate case management from admission to discharge, including ER follow‑up.
• Assess physical functioning and understand acute and chronic illnesses.
• Identify patients suitable for chronic care management and obtain authorizations.
• Develop and implement patient care goals, monitoring quality and outcomes.
• Assist patients and families with resource navigation, medication funding, and insurance issues.
• Communicate delays in services to the healthcare team.
• Provide diabetic education, smoking cessation support, and wound care management.
• Visit patients in care facilities to deliver chronic care management services.

Required profile

• Degree, license or certification as an LPN or RN.
• Strong communication, interpersonal, clerical, and organizational abilities.
• Capability to handle confidential information securely.
• Ability to type at least 40 wpm and operate computers and office equipment.

What we offer

• Health, Dental, and Vision benefits
• Life Insurance
• 401(k) with company match up to 6%
• Paid Time Off