The Registered Nurse coordinates comprehensive care for patients with multiple chronic conditions, focusing on proactive care coordination, education, and interdisciplinary collaboration to improve outcomes and ensure compliance with Chronic Care Management requirements. Responsibilities include performing nursing assessments, developing individualized care plans, conducting patient outreach, and documenting all CCM services accurately in the EHR.
Requirements summary
Candidates must be a graduate of an accredited nursing program and hold an unrestricted Registered Nurse license in New Mexico, along with Basic Life Support (BLS) certification. A minimum of one year of nursing experience in a healthcare setting is required, with preference given to experience in chronic disease management, care coordination, or an FQHC setting.
Under the direction and supervision of the Director of Nursing or designee, the Chronic Care Management Registered Nurse (CCM RN) coordinates comprehensive care for patients with multiple chronic conditions. This role focuses on proactive care coordination, chronic disease education, patient outreach, and interdisciplinary collaboration to improve patient outcomes, support value-based care initiatives, and ensure compliance with CMS Chronic Care Management requirements. The CCM RN practices in accordance with the New Mexico Nurse Practice Act, CMS guidelines, HRSA/FQHC standards, and organizational policies.
What
You
Will Do: Deliver comprehensive care coordination and chronic disease management by providing patient education, goal-setting support, and the promotion of preventive health practices through telephonic, virtual, or in-person engagement. Perform comprehensive nursing assessments to develop individualized electronic care plans while monitoring chronic disease indicators, treatment adherence, and facilitating seamless transitions of care through post-hospital follow-ups and specialty referrals. Apply independent clinical judgment and critical thinking to assess patient needs. Conduct telephone triage and escalate urgent or emergent concerns appropriately. Review laboratory, imaging, and diagnostic results related to chronic conditions and coordinate follow-up care. Address social determinants of health through referrals to community resources. Document CCM services, patient contacts, care plans, and time tracking accurately in the electronic health record. Ensure compliance with CMS Chronic Care Management billing requirements, HIPAA regulations, HRSA standards, and organizational policies. Participate in audits, reporting, and quality improvement initiatives. Collaborate with providers, medical assistants, behavioral health, pharmacy, clinic nurses, and community health workers. Support population health initiatives, UDS/HEDIS measures, and value-based care goals. Participate in care team meetings, training activities, and workflow development. Maintain accurate and timely EHR documentation. Identify and enroll eligible patients into CCM programs according to CMS, payer, and organizational guidelines. Other duties as assigned.
Minimum Qualifications
Graduate of an accredited registered nursing program. Current, unrestricted Registered Nurse license in the State of New Mexico. Minimum one (1) year of nursing experience in a healthcare setting; chronic disease management, outpatient care, care coordination, or FQHC experience preferred. Basic Life Support (BLS) certification required.
Benefits
Dental Insurance
Employee Assistance Program
Life Insurance
Paid Holidays
Vision Insurance
Medical Insurance
Flexible Spending Account
401k Retirement Plan
Education Reimbursement
Paid Sick Time
Preferred Qualifications
Bachelor of Science in Nursing (BSN). Experience in community health, FQHC, or primary care setting. Chronic Care Management or population health experience. Bilingual English/Spanish, read and write Physical Requirements: Ability to balance, bend, lift, carry, and pull up to 20 lbs. Ability to sit and stand for extended periods, typically longer than four hours. Flexibility to work a varied schedule, including evenings, weekends, or as needed. Manual dexterity and ability to use hands and fingers for feeling, grasping, and operating office equipment. Adequate hearing ability for communication and monitoring office environments. Good vision for reading documents, operating office equipment, and observing surroundings. Capability to stoop, crouch, crawl, or kneel as necessary for office tasks. Ability to talk clearly and effectively for communication. Ability to walk and move around the office environment. This position involves possible exposure to bloodborne pathogens and infectious materials.
Exposures
Airborne Pathogens Blood borne Pathogens-Category I Chemicals Electrical current; machine vibration; moving parts. Muscular and muscular strain Noise Odors, fumes, toxicants, explosive materials, and chemicals Temperature Vision and hearing strain
What We Offer
401(k) Retirement Plan 7 Paid Holidays Paid Sick Time Comprehensive Medical, Dental, and Vision Insurance 100% Employer-Paid Basic Life Insurance Voluntary Employee Supplemental Benefits Employee Assistance Program (EAP) Education Reimbursement Flexible Spending Account (FSA)
Who We Are
As a Federally Qualified Health Center (FQHC) and 501(c)(3) nonprofit, El Centro Family Health is dedicated to providing affordable, accessible, and high-quality healthcare to the people of Northern New Mexico. Our mission is to enhance the quality of life in our community by delivering primary care and health education through a network of clinics and collaborative programs. At El Centro, we are committed to offering vital health services in a compassionate, supportive, and patient-centered environment. Equal Employment Opportunity Statement: El Centro Family Health is an equal opportunity employer. We do not discriminate based on race, color, religion, gender, gender identity, sexual orientation, national origin, disability, age, veteran status, or any other protected characteristic. We are committed to fostering a diverse and inclusive workplace for all.
