Location: 100% RemoteFLEXIBLE HOURS (Set your schedule)ONLY CALIFORNIA LICENSED Job Summary We are seeking a dedicated and compassionate Physician Assistant (PA-C) or Nurse Practitioner (NP) to support our Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. In this role, you will leverage advanced clinical training to empower patients in effectively managing chronic conditions while ensuring high-quality, evidence-based care delivery. You will conduct comprehensive assessments, develop and adjust individualized care plans, and provide patient-centered education, clinical oversight, and support in collaboration with a multidisciplinary care team.
Key Responsibilities Comprehensive Patient Assessments
Perform detailed medical, psychological, and social assessments to identify patient needs and risks. Diagnose, evaluate, and manage chronic conditions in accordance with current clinical guidelines.
Individualized Care Plans
Develop, implement, and modify personalized care plans that optimize patient outcomes. Collaborate with physicians, pharmacists, and care managers to ensure integrated, coordinated care.
Patient Education and Engagement
Counsel patients on disease management, medication adherence, lifestyle modification, and preventive care. Use motivational interviewing and behavior-change strategies to engage patients in their health journey.
Care Coordination & Clinical Oversight
Facilitate seamless communication among patients, caregivers, and the healthcare team. Review test results, monitor disease progression, and provide follow-up to prevent complications or gaps in care.
Data Monitoring and Interventions
Monitor RPM data for early warning signs and initiate timely clinical interventions. Use population health insights to guide proactive outreach and risk reduction strategies.
Documentation and Compliance
Document all patient encounters, care plans, and interventions in the EHR accurately and promptly. Ensure compliance with CMS and other regulatory requirements for CCM and RPM.
Program Support & Leadership
Oversee patient enrollment into CCM and RPM programs. Support quality improvement initiatives, program effectiveness, and patient satisfaction tracking.
Qualifications and Requirements Education & Certification
Active, unrestricted California Physician Assistant (PA-C) or Nurse Practitioner (NP) license. National certification (NCCPA for PA-Cs; AANP or ANCC for NPs) is required.
Experience
Minimum 2 years of clinical experience in primary care, internal medicine, geriatrics, or chronic disease management. Experience with CCM, RPM, or value-based care models is strongly preferred.
Technical Skills
Proficiency in electronic health records (EHR). Familiarity with RPM devices, data platforms, and telehealth technologies.
Soft Skills
Strong clinical judgment and decision-making skills. Excellent interpersonal and communication abilities for patient education and interdisciplinary teamwork. Highly organized with the ability to manage multiple priorities in a remote setting.
Work Environment
Reliable internet connection and a HIPAA-compliant workspace for telehealth and virtual care delivery.