El Centro Family Health·Espanola, New Mexico
The Registered Nurse coordinates comprehensive care for patients with multiple chronic conditions, focusing on proactive care coordination, patient education, and interdisciplinary collaboration to improve outcomes and ensure compliance with CMS requirements. Key duties include performing comprehensive nursing assessments, developing individualized care plans, conducting telephone triage, and documenting all CCM services accurately in the EHR.
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.
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.
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.
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.
Market context
In New Mexico, nursing roles that support home health, long-term care, and developmentally disabled patients are often in steady demand, especially when agencies need licensed RNs who can work independently. These positions are competitive because employers value a current New Mexico RN license, a valid driver’s license, required insurance, and experience in related care settings. Review the AI-summarized requirements and benefits here to save time, then confirm the original posting for any scheduling, documentation, or travel expectations before applying.