CircleLink Health

Nurse

• Call a full caseload of Medicare patients with two or more chronic conditions monthly using specialized care management software
• Build and maintain rapport with patients through SMART goals and self-management education
• Implement and improve patient Plans of Care by updating medications, appointments, biometrics, symptoms, and interventions
• Connect patients with community resources, including transportation, personal care, prescription/DME assistance, and social services
• Conduct Transitional Care Management activities for high-risk patients discharged from hospitals and emergency rooms
• Close preventive care gaps by encouraging wellness visits, vaccinations, cancer screenings, and follow-up or specialist appointments
• Provide accurate, timely, and complete documentation
• Prioritize and close case tasks on schedule while meeting quality, compliance, and performance expectations

Licensed Registered Nurse Care Coach

Clinical Specialist

• Transfer clinical documentation into customer EHR systems accurately and without alteration
• Maintain documentation accuracy and protect patient confidentiality (HIPAA-compliant)
• Follow established clinical-support workflows
• Collaborate with our care management and operations teams

Clinical Staff EHR Data Transfer Specialist – Contract

Coach

• Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis
• Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies
• Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made
• Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc.
• Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions.
• Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.

Registered Nurse – Care Coach

• Run monthly clinical calls with chronic care patients
• Drive behavior change through coaching and education
• Maintain precise, compliant documentation using our platform
• Close preventive care gaps and coordinate services
• Update care plans and track interventions
• Support transitions of care to reduce readmissions
• Manage your panel efficiently and consistently

RN Care Coach

• Utilize our specialized care management software to call a full caseload of Medicare patients with two or more chronic conditions on a monthly basis
• Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies
• Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made
• Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc.
• Conduct Transitional Care Management activities to high-risk patients discharged from the hospital and reduce unnecessary readmissions
• Close care gaps by encouraging preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up appointments, etc.

• Manage a large 100+ panel of Medicare patients with chronic conditions
• Run monthly clinical calls with chronic care patients
• Drive behavior change through coaching and education
• Maintain precise, compliant documentation using our platform
• Close preventive care gaps and coordinate services
• Update care plans and track interventions
• Support transitions of care to reduce readmissions
• Manage your panel efficiently and consistently

Licensed Registered Nurse Care Coach

Clinical Staff EHR Data Transfer Specialist – Contract

Registered Nurse – Care Coach

RN Care Coach

Licensed Registered Nurse Care Coach

RN Care Coach – High Performance Role

Clinical Staff EHR Data Transfer Specialist – Contract