RN or Physician Assistant (PA) – Chronic Care Clinician (Telehealth)

Job Overview The Physician Assistant would play a key role in supporting patients with chronic conditions through ongoing care coordination, telehealth engagement, and exceptional customer service. This role involves conducting routine outreach calls including patient denial follow up, educating patients about Chronic Care Management (CCM) services, Principal Care Management (PCM) assisting with enrollment on behalf of providers, addressing denial patients and helping patients navigate their care plan to improve health outcomes and reduce barriers to care. In addition, this role will collaborate with care managers and support staff to develop, monitor, and adjust patient care plans while ensuring compliance with CMS requirements. This role focuses on improving patient outcomes, enhancing quality measures, reducing avoidable hospitalizations, and supporting a proactive, patient-centered approach to chronic disease management. The role also includes reviewing clinical information for claims accuracy, supporting prior-authorization needs, identifying care gaps, and communicating with providers or leadership to ensure continuity of care. Key Responsibilities Patient Outreach & Enrollment • Call eligible patients on behalf of their provider to explain CCM/PCM services. • Conduct outreach to patients who previously declined program participation. • Complete compliant CCM/PCM enrollment including informed consent and eligibility verification. • Document all outreach attempts and enrollment activity in the EMR. Telehealth & Care Coordination • Complete monthly telehealth check-ins with enrolled CCM/PCM patients. • Review health status, medications, vitals (as reported), and goal progress. • Identify care gaps, risk factors, or social determinants affecting outcomes. • Escalate clinical concerns to supervising providers or care managers. • Support patient adherence to orders, follow-up visits, and prescribed care plans. Claims Review & Documentation • Review clinical documentation for accuracy related to CCM/PCM billing. • Assist with claim clarifications, denials, or missing clinical elements. • Ensure monthly clinical time requirements are met and documented. • Support internal audits, quality checks, and CMS-compliance reviews. • Maintain precise, timely EMR notes that meet all regulatory standards. Customer Service & Patient Support • Provide clear, compassionate communication to patients and caregivers. • Educate patients on chronic-disease self-management and preventive care. • Serve as a patient advocate, helping resolve questions, barriers, or concerns. • Coordinate follow-up needs with providers and clinic staff. Quality Improvement & Program Support • Participate in case reviews, care-team huddles, and interdisciplinary communication. • Assist leadership in enhancing workflows and implementing evidence-based practices. • Monitor performance indicators (e.g., engagement, adherence, satisfaction). • Contribute to program development and continuous improvement initiatives. Qualifications Required • Active and unrestricted Registered Nurse (RN) or Physician Assistant (PA) license. • Experience in chronic-care management, care coordination, triage, or ambulatory care. • Strong telephonic communication and patient-education skills. • Familiarity with EMRs and telehealth workflows. • Ability to work independently and manage multiple patients. • Strong attention to detail and comfort with documentation and claims review. Preferred • Experience with CCM, PCM, care management, or population health. • Knowledge of Medicare, CMS billing requirements, and value-based care. • Experience in claims review, prior authorization, or UM/UR. • Bilingual abilities. Work Environment • Remote or Hybrid • High volume of outbound telehealth calls and claims-related review tasks. • Collaboration with providers, care managers, coding/billing teams, and administrative staff. Job Type: Full-time Pay: $70,000.00 - $87,000.00 per year Benefits: • 401(k) • 401(k) matching • Dental insurance • Health insurance • Paid time off • Professional development assistance • Vision insurance Application Question(s): • How many years of experience do you have working with chronic-care management, care coordination, triage, or ambulatory care. • How many years of experience do you have working in telehealth? License/Certification: • PA-C or RN (Required) Work Location: Remote