Review patient charts, medications, labs, and care plans• Coordinate care with providers, nursing staff, pharmacies, and families when needed• Document patient interactions accurately and thoroughly• Identify changes in condition and escalate concerns appropriately• Assist with chronic disease management and patient education• Ensure PCM services are completed in compliance with CMS guidelines. • Active RN license required• Nursing home or long term care experience preferred• Experience with chronic care management or PCM is a plus• Strong communication and organizational skills• Comfortable working independently in a remote environment• EMR experience preferred.