Virtual Chronic Care Management Nurse (Contractor)

Who we are. . .

Pearl Health is restoring the independence and joy of practicing medicine for doctors in the United States. Our healthcare system has burdened our doctors with too much process, while removing them from what they do best: caring for those we love most. We are a team of physicians and public health experts (Stanford, Dartmouth, Harvard, Mass. General), technologists (athenahealth, Apple, Amazon, Meta, Flatiron, WalMart Health), healthcare innovators (Oscar, Aledade, Stellar, Arcadia) and experienced risk management professionals (CVS/Aetna, Humana, Cigna, United) who believe that primary care providers (PCPs) are the key to the United States’ future health. Pearl recently announced a strategic partnership to proliferate value-based care with Walgreens, one of the largest healthcare companies in the country. Our investors include Andreessen Horowitz, Viking Global Investors, AlleyCorp, and SV Angel.

Pearl Health helps PCPs who are overwhelmed by the demands of an aging population and the unpredictable business model inherent to Traditional Medicare. Over time, this solution will empower PCPs to provide better care to their entire patient population. We believe there is a need to bring humanism back to healthcare by giving physicians the ability to better allocate their time with patients, increasing their autonomy, creating incentives that are aligned with achieving better outcomes through clinical decision-making powered by actionable intelligence, and making care delivery more efficient and sustainable. The Center for Medicare and Medicaid (CMS) is launching a new value-based care program to disrupt Traditional Medicare, and we believe that this represents an opportunity to achieve the meaningful change we envision.

The role. . .

Pearl Health is seeking a skilled and dedicated Registered Nurse to join our team on a contract basis to work 40 hours per week as a Virtual Chronic Care Manager. In this role, you will be responsible for managing high- and rising-risk patients eligible for chronic care management across 2-5 practices, providing virtual care and support. The ideal candidate will have experience in navigating complex patient care scenarios, engaging with patients virtually, and be comfortable utilizing various electronic health record (EHR) systems. The estimated length of this contract engagement would be seven months, with potential for extension.

This role offers a unique opportunity to be at the forefront of evolving virtual care models, contributing to the development of efficient and effective patient management strategies that deliver virtually delivered value-based care with a focus on population management and enhancing population health.

Key responsibilities include:

• Conduct initial and ongoing virtual assessments to capture patients' health goals, especially during intake, and provide updates to assessments as necessary.

• Provide patients and their families with comprehensive education about their conditions, treatment options, and self-management strategies to empower them in their care.

• Where appropriate, escalate patient needs through designated Clinical Champions at Pearl’s partner practices and ensure the practice facilitates what is clinically needed by the patient and coordinates with the patient and family.

• Conduct medication reconciliation with the patient. Educate patients on their prescribed medications, addressing any questions and ensuring there are no barriers to obtaining and taking their medications regularly.

• Monitor patient compliance with medication regimens via check-in and document any continued chronic disease symptoms the patient is having. Escalate to Practice Clinical Champion if there may be a need for re-evaluation of med regimen.

• Develop and maintain a low-friction communication channel via text message for patients and families to use in case of questions or symptom exacerbation, leveraging various communication tools and patient engagement technologies as appropriate.

• Coordinate with practice’s Clinical Champion and, where appropriate, with family members to manage patient-specific needs such as appointment scheduling and follow-ups.

• Efficiently manage patient outreach and virtual communications, prioritizing interactions based on clinical need and program goals.

• Document all patient interactions, care plans, and clinical updates accurately and efficiently in the practice’s electronic health record (EHR) systems AND within emerging care management platforms.

• Actively participate in refining care workflows and utilizing new tools and technologies designed to enhance patient engagement, streamline documentation, and improve care coordination.

• Provide constructive feedback on care management tools and processes to support continuous improvement and the effective integration of technology into clinical practice.

• Ensure all care provided aligns with current best practices and regulatory requirements in chronic care management.

• Engage in ongoing learning to stay abreast of developments in chronic care management and integrate new evidence-based practices into patient care.

• Other duties as assigned.

Who you are. . .

• Bachelor's degree in Nursing (BSN) from an accredited institution; Master's degree in Nursing (MSN) preferred.

• Active Registered Nurse (RN) license in good standing.

  • Active RN license in multiple states and/or compact state preferred.

• Minimum of 2 years of clinical experience in a healthcare setting in chronic care management, preferably for Medicare beneficiaries.

• Strong communication skills, both pop verbal and written, with the ability to engage and motivate patients virtually.

• Proficiency with Electronic Health Records (EHR) systems, with experience using multiple major EHRs preferred, and a strong aptitude for learning and adapting to new healthcare software and virtual care platforms.

• Comfortable with technology and willing to adapt to new virtual care platforms and tools.

• Excellent time management and organizational skills, with a proven ability to prioritize tasks, manage patient communications effectively, and maintain focus in a virtual care setting.

• Ability to work independently and manage a diverse caseload efficiently.

• Ability to collaborate effectively with multidisciplinary teams and across different healthcare practices.

• Ability to collaborate effectively with internal Pearl teams (including clinical, operational, and technical members) to identify opportunities to refine our value-based care performance model, while demonstrating resourcefulness and self-sufficiency in navigating challenges and finding innovative solutions.

• Comfortable working in a dynamic environment where processes and tools evolve to improve patient care and operational efficiency.

• Proactive, solutions-oriented, and demonstrates initiative with minimal supervision, with an interest in contributing to the enhancement of care delivery models.

Our Values

We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share a passion for improving people's lives. Our definition of diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. We believe all of our colleague’s points of view are integral to our success, and that inclusion is everyone's responsibility and a cause of beautiful things.

We welcome candidates from all backgrounds and are committed to a fair hiring process free from discrimination and focused around problem solving, improvement, and mutual empowerment.

Compensation and Benefits

The salary range Pearl Health expects to pay for this position is $35-$45/hour.

Remote Work

We are a remote-first company, with a concentration of team members at our NYC headquarters and in the Boston area.

Agency Submissions

We are not currently working with contingency search firms. If a resume is submitted to any Pearl Health employee by a third party without a valid written and signed search agreement, it will become the property of Pearl Health and no fee will be paid, irrespective of whether the candidate is hired.