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Registered Nurse Care Coach at CircleLink Health. This is a remote role.. CircleLink Health is looking for passionate, tech savvy registered nurses to work remotely and serve patients enrolled in Medicare’s Chronic Care Management Program. In this . part time role. (20-25 hrs. per week), an RN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital.. Key Responsibilities:. . Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis. . Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies. . Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made. . Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc.. . Conduct Transitional Care Management activities to high-risk patients discharged from the hospital and the ER to reduce unnecessary readmissions.. . Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.. . . Fluent in English. . Self-directed, able to work independently with little supervision while meeting performance metrics. . Passion for nursing and improving patient outcomes. . Good with technology and eager to learn and use new software. . Excellent organizational and time management skills. . Strong communication and telephonic skills. . Strong critical thinking and problem-solving skills. . Education and Experience:. . Current, unrestricted New York license. . . Proficiency with EHRs (electronic health records) and web-based applications . . 3+ years' experience as a Registered Nurse. . Preferred Education and Experience, but not required:. . Case Management or Chronic Disease Management experience . highly. preferred. . Certified Diabetes Educator. . Experience with Motivational Interviewing or other behavior change communication techniques. . Scheduling and Other Requirements. . Must have a STRONG internet-connected computer. Computer and internet speed tests will be required. . . Minimum of 20-25 hours of availability per week required.. . You will commit to your own schedule using our software.. . This is a 1099 contract position with no end date. Care coaches are responsible for their own taxes and insurance.. . Company Location: United States.