• Review electronic health records (EHR) to identify gaps in care for patients residing in a Long-term Care Nursing Facility.
• Review and approve initial and ongoing health questionnaires completed by a member of the care management team.
• Serve as a health coach to educate patients and/or caregivers about their disease process.
• Develop patient-centered care plans.
• Educate patients and their durable medical power of attorney (DPOA) on the benefits of APCM or CCM.

• Support quality gap closure through clinical discovery.
• Schedule Provider visits for at-risk patients
• Coordinate with the Transitional Care Manager to schedule patient visits and inform the TCM nurse if a patient is discharged to acute or SNF.
• Ensure orders, referrals, and prior authorizations are facilitated by the virtual care support team.
• Escalate abnormal diagnostic test results to Curana providers.

• Communicate patient health updates to the Curana providers.
• Communicate treatment plans and health updates to the patient’s caregiver in an effective and caring manner.
• Primary liaison between the provider and administrative support team.

Other duties as assigned

• Exhibits knowledge of pathophysiology and accepted treatment protocols for common health diagnoses (i.e., diabetes, chronic heart failure, chronic obstructive pulmonary disease).
• Ability to analyze patient records to identify gaps in care and report to the provider.
• Ability to work in a remote environment that is free of distractions.
• Proficient computer skills and ability to adapt to various technology platforms.
• Excellent written communication skills.
• Demonstrated experience in the usage of clinical data to guide decision making.
• Must have the ability to function independently and as a member of the interdisciplinary care team.

Required Education and Experience

• Must hold an active, unrestricted compact LPN license.
• Ability to obtain additional state licenses, as needed
• 2+ years of experience in nursing is required. Care settings may include inpatient, outpatient, or skilled nursing facilities.

Preferred Education and Experience

• Case Management experience
• CCM certification (strongly preferred)
• Experience working with Electronic Health Records

• 100% remote position requires a reliable high-speed internet connection.