Join our expanding Chronic Care Management (CCM) team within Avance Care, a leading network of 37 practice locations across the Triangle Area (Raleigh-Durham-Chapel Hill), the Charlotte Region, and Wilmington, NC.

At Avance Care, we are dedicated to elevating the standard of healthcare. As one of North Carolina's largest networks of independent primary care practices, we provide comprehensive, patient-centered services that support the physical, mental, and emotional well-being of our patients.

We are recruiting for a Registered Nurse (RN) to join our Chronic Care Management (CCM) team. This role will support comprehensive, patient-centered care for a designated population while optimizing health outcomes. The CCM RN Coordinator is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care plans as patients transition across the care continuum.

• This is a hybrid role based at our headquarters in Durham, combining in-office and remote work for a balanced schedule.
• Supportive Work Environment: We provide a collaborative and encouraging atmosphere where your contributions directly enhance patient health and well-being. You'll also have opportunities for professional growth while making a meaningful impact in the lives of those we serve.
• Comprehensive Benefits: Our robust benefits package becomes available starting on the first of the month following 30 days of employment.

Selected Responsibilities:

• Review patients’ medical and social health status using electronic medical records, claims data, and community resources.
• Conduct outreach to confirm diagnoses, contributing factors, anticipated treatment plans, and barriers to care.
• Facilitate access to necessary care by navigating barriers, advocating for patients, and educating families/caregivers.
• Monitor patients enrolled in care management to ensure treatment goals are met and shared across care teams.
• Track and support patients post-hospitalization or ER visits to ensure continuity of care and reduce readmission risks.
• Assist in primary care provider triage assessment and direct patients to appropriate services.
• Provide clinical supervision for LPNs, MAs, and CNAs in case conferencing and approve care plans.
• Coordinate patient case assignments based on the clinical abilities of paraprofessional staff.
• Maintain accurate documentation in the electronic medical record and communicate updates to care teams.
• Identify workflow improvements to enhance cost-effective, high-quality care delivery.
• Stay updated on healthcare regulations, trends in ambulatory and cross-continuum care, and accountable care organizations.
• Utilize information technology to identify high-risk patients and address care gaps.
• Develop and maintain relationships with internal and external stakeholders.

Candidates should have a related degree (ADN or BSN), an active Registered Nursing license, and at least 3 years of direct patient care experience. Preferred qualifications include experience in Case Management, home health nursing, health coaching/education, medication administration, or geriatric care.

Other Priorities:

o Strong verbal and written communication
o Ability to maintain confidentiality and integrity
o Growth mindset
o Flexibility and resilience
o Knowledge of common medical terminology and HIPAA regulations.
o Ability to work collaboratively in a team-oriented environment.

If you’re passionate about improving chronic care management and making a meaningful impact on patient health in North Carolina, we encourage you to submit your resume.

Avance Care provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, gender identification, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.

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