Job detail

Bilingual RN Care Coach - Bonus Eligible

CircleLink Health

#Case Management #Registered Nurse #Accountability #Documentation #Education #Bilingual #Remote #Patient Care #Care Coordination

Quick overview

The RN Care Coach will remotely serve Medicare patients enrolled in Chronic Care Management by providing monthly educational calls, coordinating care, closing preventive care gaps, and coaching self-management strategies to reduce hospitalizations. Key duties involve utilizing specialized software to call patients with chronic conditions, updating care plans, connecting patients with resources, and conducting transitional care management activities.

Requirements summary

Candidates must possess a current, unrestricted Multistate RN or New Mexico RN license and fluency in both English and Spanish is mandatory. The role requires strong discipline, excellent documentation skills, high organizational ability, and the capacity to work independently while meeting performance metrics, preferably with 3+ years of RN experience.

bachelor degreeCommunicationTime ManagementProblem-SolvingOrganizational SkillsDocumentationIndependent WorkPatient EducationCare CoordinationAccountabilityCritical ThinkingMotivational InterviewingTechnology ProficiencyChronic Disease ManagementSelf-Management CoachingTransitional Care Management

Job description

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 (about 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.
This Role Requires Precision, Discipline, and Accountability The Care Manager role is not a step back from bedside nursing — it’s a step into a more complex, structured, and performance-driven environment.
To succeed, you must bring more than clinical knowledge: ✅ Excellent documentation skills — Your charting must be complete, timely, and accurate. ✅ Strong time management — Case tasks must be prioritized and closed on schedule. ✅ Ownership of outcomes — Each case is closely tracked for quality, compliance, and effectiveness.
Expectations are high, and performance is regularly reviewed.
This is not a role where details can be missed or timelines pushed — we need professionals who take initiative, stay organized, and consistently deliver.
If you’re ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.
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 and Spanish is a must 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 Timely communication is essential, and nurses are expected to respond to all messages and emails within 24–48 hours.

Bilingual RN Care Coach - Bonus Eligible

Quick overview

Requirements summary

Job description

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