Position Overview:We are seeking a compassionate, skilled, and bilingual (Arabic/English) Registered Nurse (RN) to join our Value-Based Care team. This role is dedicated to supporting patients enrolled in our Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring (RPM) programs at our Medical Center. The ideal candidate thrives in a telephonic care coordination environment, is passionate about chronic disease management, and is committed to building trusting, long-term relationships with patients through consistent outreach and education — without traditional bedside or in-person clinical duties.
Key Responsibilities:• Manage an assigned panel of patients enrolled in CCM, PCM, and RPM programs through regular telephonic outreach and follow-up• Conduct structured phone-based assessments, medication reviews, and care plan check-ins in both English and Arabic• Monitor and review remote patient monitoring (RPM) data, identifying clinical changes and escalating concerns to the supervising physician or NP in a timely manner• Collaborate with physicians, nurse practitioners, and the care team to develop, implement, and update individualized care plans• Educate patients and their families — in both English and Arabic — on chronic disease self-management, medication adherence, warning signs, and healthy lifestyle practices• Document all care management activities accurately and in compliance with CMS guidelines for CCM and PCM billing (including monthly time tracking)• Proactively identify care gaps, social determinants of health, and barriers to care, and coordinate appropriate referrals and resources• Support patient enrollment and consent processes for CCM, PCM, and RPM programs• Ensure full compliance with HIPAA regulations, CMS value-based care standards, and Medical Center policies• Maintain thorough and timely documentation in the Electronic Health Record (EHR)
Qualifications:• Current, valid Registered Nurse (RN) license in the State of Michigan (required)• Associate Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred• Arabic/English bilingual proficiency — spoken (required)• CPR/BLS certification (required)• Experience with CCM, PCM, or RPM programs strongly preferred• Strong clinical knowledge of chronic disease management (diabetes, hypertension, COPD, heart failure, CKD, etc.)• Proficiency with EHR systems and remote patient monitoring platforms• Excellent communication, empathy, and patient engagement skills• Ability to manage a large patient panel, meet monthly documentation requirements, and work independently• Prior experience in an outpatient, care management, or value-based care setting preferred
Benefits:• Health insurance• Paid time off (PTO)• Flexible scheduling• Opportunities for professional growth and development in value-based and population health• Pay: $26 – $34 per hour (commensurate with experience)Work Location: In-Person | Medical Center – RemoteIf you are a bilingual RN who is passionate about proactive, patient-centered chronic care and wants to make a meaningful difference in the lives of patients managing complex conditions, we encourage you to apply.
Powered by JazzHR