Registered Nurse Care Coach

Our Mission:
CircleLink Health® is a company of passionate clinicians, technologists and business people tackling the $600B problem of preventable chronic condition complications. Our mission is to accelerate the shift to preventative care (from status quo reactive care) through our world-class preventative care platform.
Your Impact On Our Mission:
As an RN Care Coach you will work remotely for 20-25 hours per week with a team of nurses to manage patients with chronic conditions enrolled in Medicare's Chronic Care Management program.
Your day to day is...

• Educating patients on self-management skills and goal setting. Chronic conditions include: Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, Depression.
• Implement and improve the Plan of Care by updating medications, appointments due, record biometrics, vital signs, and Care Coaching provided.
• Utilize Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management.
• Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions, including medication reconciliation, medication adherence, identify red flags, address barriers, encourage follow-up care, how and when to seek appropriate level of care.
• Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
• Connect the patient with community resources as needed, including transportation, personal care needs, homemaker or chore services, social services, etc.

Requirements
Required Skills and Abilities:

• Fluent in English.
• Meet communication skills, must be self-directed, able to work independently with little supervision while meeting performance metrics
• Passion for nursing.
• Detail-oriented.
• Excellent organizational and time management skills.
• Strong communication and telephonic skills.
• Strong critical thinking and problem solving skills.
• Commitment to certain number of hours per day and days of week
• Availability to make calls on weekdays between 9am-6pm.
• RN needs a STRONG internet-connected computer.

Education and Experience:

• Current, unrestricted Oregon RN license (OR is a NOT a Compact State)
• Proficiency with electronic health records and web based applications
• 5+ years experience as a Registered Nurse

Preferred Education and Experience, but not required:

• Case Management or Chronic Disease Management experience
• Case Management Certification
• Certified Diabetes Educator
• Transitional Care Management experience
• Experience with Motivational Interviewing or other behavior change communication techniques

Benefits
Compensation:
This is a 1099 contract position with no end date. Care Coaches are responsible for their own taxes and insurance.
Compensation is paid at the rate of $15.00 per initial Clinical Encounter per patient per month. A clinical encounter occurs after two criteria are met: a patient has a successful clinical call, and the patient has 20 minutes or more of time in their chart timer.
Example: If in one hour you called and spoke with 2 patients and spent 30 minutes with each of them, your pay for that hour would be $30.00 ($15.00/pt reached x 2).
Also, Coaches receive $6.00 if patients go unreachable after 5 call attempts and $4.00 if the patient withdraws.
About CircleLink Health:
CircleLink is a digital healthcare company that improves health for the chronically ill by engaging patients through personal phone calls and/or mobile technology, helping to solve the ~$600 billion problem of preventable chronic complications. Our patient engagement software and services enable physicians to monitor and manage their patients' chronic conditions between office visits without investing in additional staff or technology.