Nurse Practitioner Chronic Care Management
Company: Vitality Home Health Care
Location: Springfield
Posted on: February 16, 2026
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Job Description:
Job Description Job Description Benefits: Competitive salary
Flexible schedule Opportunity for advancement About Us: We are a
growing home care agency expanding our Chronic Care Management
(CCM) and care coordination services to better support patients
with multiple chronic conditions. Our mission is to improve
outcomes, reduce hospitalizations, and provide proactive,
patient-centered care in collaboration with caregivers, families,
and providers. Position Summary: We are seeking a Nurse
Practitioner (NP) to lead and support our Chronic Care Management
program . This role focuses on care coordination, clinical
oversight, patient education, and interdisciplinary collaboration
for patients with two or more chronic conditions. The ideal
candidate is organized, compassionate, and experienced in managing
complex patients outside of traditional office visits. Key
Responsibilities Conduct comprehensive CCM assessments and ongoing
monthly care management Develop, implement, and update
individualized care plans Monitor chronic conditions (e.g., CHF,
COPD, diabetes, hypertension, dementia) Coordinate care with
physicians, specialists, caregivers, and community resources
Provide patient and family education and support via phone or
telehealth Identify gaps in care and intervene proactively to
prevent hospitalizations Document CCM activities accurately in
accordance with Medicare guidelines Support compliance with CMS CCM
requirements and quality measures Collaborate with agency
leadership to grow and enhance the care management program
Qualifications Active Nurse Practitioner license (state-specific)
National NP certification (AANP or ANCC) Minimum 2 years of
clinical experience (primary care, geriatrics, home care, or care
management preferred) Experience with chronic disease management
and care coordination Familiarity with Medicare CCM services and
documentation requirements (preferred) Strong communication,
organization, and time-management skills Comfortable working
independently in a remote or hybrid environment EMR experience
required What We Offer Competitive compensation Flexible schedule
(ideal for work-life balance) Opportunity to help build and shape a
growing CCM program Collaborative, mission-driven work environment
Supportive leadership and administrative support Flexible work from
home options available.
Keywords: Vitality Home Health Care, Elizabeth , Nurse Practitioner Chronic Care Management, Healthcare , Springfield, New Jersey
