About the job
Join our team remotely as a Part-Time Bilingual LPN Care Coach! CircleLink Health is seeking dedicated and technology-savvy nurses to assist patients enrolled in Medicare's Chronic Care Management Program. In this part-time position (approximately 20-25 hours per week), you will be responsible for a group of patients, engaging with them through monthly calls. During these calls, you will provide essential education, coordinate care, address preventive care gaps, and guide patients in self-management strategies to help them avoid hospital visits.
This role demands precision, discipline, and accountability.
The Care Manager position is an opportunity to step into a more structured and performance-oriented environment rather than stepping back from bedside nursing. Success in this role requires more than just clinical expertise:
Exceptional documentation skills — Your charting needs to be comprehensive, timely, and accurate.
Strong time management — You must prioritize cases and complete tasks on schedule.
Commitment to outcomes — Each case will be meticulously monitored for quality, compliance, and effectiveness.
With high expectations and regular performance reviews, this position is not for those who overlook details or miss deadlines. We seek professionals who take initiative, remain organized, and consistently meet or exceed expectations.
If you are ready for a fast-paced environment where your contributions are valued and make a meaningful impact, we encourage you to apply.
Key Responsibilities:
- Utilize specialized care management software to communicate with Medicare patients diagnosed with two or more chronic conditions (such as Diabetes, CHF, Chronic Pain, COPD, etc.) monthly.
- Develop and maintain a strong rapport with patients, coaching them towards better health through SMART goals and education on self-management techniques.
- Enhance and adjust the Plan of Care by updating medications, due appointments, biometrics, symptoms, and interventions.
- Connect patients with essential community resources, including transportation, personal care, prescription/DME assistance, and social services.
- Execute Transitional Care Management activities for high-risk patients recently discharged from hospitals or ERs to minimize unnecessary readmissions.
- Encourage and assist with preventive care measures, such as annual check-ups, vaccinations, cancer screenings, and follow-ups with specialists, to close care gaps.