IMCS Group Visa Sponsorship Jobs USA

Job Title: RN Case Manager - Chronic Care Management
Duration: 6 months contract
Location: Remote- TX
Shift Type: Part-time, 4-5 hours a day flexible. 20 hours per week initially. (There is a high likelihood that the part-time role may transition into a full-time position at 40 hours per week)
Payrate: $42-46/hr

Job Responsibilities:

- Manage an assigned panel of Medicare patients with 2 or more chronic conditions
- Conduct, at minimum, monthly outreach to CCM-enrolled patients via phone, secure messaging, or mobile application
- Track and document time spent on care coordination activities per patient per calendar month in the clinical portal.
- Create, revise, and monitor individualized electronic care plans addressing the patient's physical, mental, cognitive, psychosocial, functional, and environmental needs
- Share updated care plans promptly within and outside the practice as appropriate; provide copies to patients and caregivers when necessary.
- Coordinate care with home- and community-based providers, specialists, and ancillary services
- Follow up with patients following ED visits, hospital discharges, skilled nursing facility stays, or other care transitions
- Create and exchange continuity-of-care documents with other treating practitioners
- Document all coordination activities, psychosocial needs, and functional decline communications in the patient's medical record.
- Review patient medications monthly and assess for potential drug interactions or adherence issues
- Oversee and support patient medication self-management
- Ensure patients are receiving timely recommended preventive services as recommended by PCP
- Accurately document all CCM activities, time, and patient interactions in the clinical portal in real time or same day
- Ensure all documentation meets CMS requirements for medical record content, care plan elements, and time-based billing
- Assist in monitoring for concurrent billing restrictions (e.g., RPM/RTM, hospice, ESRD codes)
- Participate in internal audits and quality reviews as requested by the billing practitioner or practice administrator

Performance Expectations:

- Monthly patient contact rate - ≥ 90% of enrolled panel contacted each month
- Time documentation accuracy - 100% of CCM time documented in EHR prior to billing submission
- Care plan currency - All active patients have a current care plan reviewed at least quarterly.
- Transition follow-up - Outreach documented within 48 hours of reported ED visit or discharge
- Audit readiness - Documentation supports billed code on review, no unsupported claims

Required Qualifications:

- Current, unrestricted Registered Nurse (RN) license in the State of Texas
- Minimum 2 years of clinical nursing experience, preferably in primary care, care management, or chronic disease management
- Strong working knowledge of chronic conditions including diabetes, hypertension, COPD, cardiovascular disease, depression, and other Medicare-prevalent diagnoses
- Experience using electronic health records (EHR); athenahealth experience preferred
- Demonstrated ability to conduct patient outreach and care coordination by phone and electronic communication
- Ability to work independently under general supervision with strong self-management and time tracking discipline
- Excellent verbal and written communication skills
- Reliable internet access

Preferred Qualifications:

- Certified Case Manager (CCM) credential or willingness to pursue certification a plus
- Prior experience in a Medicare CCM or care management program a plus
- Familiarity with CMS billing and documentation requirements for CCM (CPT 99490, 99439, 99487, 99489)
- Experience with motivational interviewing or patient engagement techniques
- Bilingual (English/Spanish) a plus