Remote Registered Nurse (RN) – Team-Based Primary Care, MA

THE ORGANIZATION Outer Cape Health Services (OCHS) provides a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod. With locations in Harwich Port, Wellfleet and Provincetown, OCHS cares for more than 20,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966). As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it and validating that staff are working at the top of their licensures are foundations of this model. Outer Cape Health Services, Inc. (OCHS) is a 501(c)(3) non-profit organization and is governed by a Board of Directors representative of its community. All board members live on Cape Cod, and the majority are OCHS patients. OCHS offers competitive benefit plans and is an inclusive and equal opportunity employer. Primary Purpose of Position: The Remote Nurse is a key member of the Outer Cape Health Services (OCHS) clinical team, delivering high-quality, patient-centered care in a virtual environment. This position supports providers, medical assistants, behavioral health specialists, and other team members to ensure timely, coordinated, and comprehensive care for patients. The remote nurse will focus on triage, care coordination, chronic disease management, and panel management, leveraging technology and clinical protocols to maintain continuity of care and close care gaps. Essential Functions Direct Patient Care & Clinical Support

• Conduct nurse visits via telehealth for chronic disease management, blood pressure checks, INR reviews, medication education, and post-hospital discharge follow-up.

• Perform triage using approved clinical protocols, assess patient needs, and coordinate same-day care when necessary.

• Exhibit a high level of clinical acumen and decision-making to address patients’ acute and chronic needs as part of a highly functioning team.

• Reinforce treatment plans for chronic conditions (e.g., diabetes, hypertension, asthma).

• Process medication refill requests per standing protocols and ensure accurate documentation.

• Educate patients on proper use of medical equipment, prescribed regimens, and other self-care practices.

• Provide a patient-centered experience by addressing questions, explaining procedures or testing, and connecting patients with community resources or support programs.

Care Coordination & Panel Management

• Collaborate with providers and team members to close care gaps and ensure follow-up on labs, referrals, and preventive services.

• Participate in pre-visit planning, leveraging standing orders to improve care delivery.

• Review dashboards and outreach to patients to schedule recommended visits and screenings.

• Assist with care transitions and follow-up after hospital or ED discharge.

Team-Based Care & Quality Improvement

• Actively participate in virtual team huddles, case conferences, and interdisciplinary care planning.

• Support population health initiatives and quality improvement projects to advance OCHS’ strategic goals.

• Facilitate coordination with specialty care, social services, and community-based resources to meet patient needs.

Documentation & Compliance

• Maintain accurate and timely documentation in the Electronic Medical Record (EMR) per OCHS policies.

• Manage all assigned in-baskets including telephone encounters, patient messages, and overdue results.

• Perform pre-visit medication reconciliation when indicated.

• Communicate abnormal and normal results promptly to providers and patients.

• Ensure compliance with HIPAA, infection control standards, and organizational clinical protocols.

Collaboration & Communication

• Promote teamwork by collaborating with providers, Medical Assistants, and Patient Service Representatives.

• Seek guidance from the Nurse Manager for escalated concerns or complex clinical issues.

• Contribute to a culture of safety by adhering to National Patient Safety Goals (e.g., patient identification, medication safety, infection prevention).

Work Environment

• Fully remote position with reliable high-speed internet required.

• Occasional on-site meetings or trainings may be required.

• Must maintain a HIPAA-compliant home office environment for patient confidentiality.

Documentation & Compliance

• Maintain patient records with accurate and timely documentation in the Electronic Medical Record (EMR) in accordance with OCHS policies.

• Ensure compliance with infection control standards, medication safety, and clinical protocols.

• Maintain patient privacy and confidentiality of information at all times in accordance with OCHS policies and HIPAA.

Non-Essential Functions:

• Attend periodic staff meetings.

• Adhere to OCHS policies.

• Adhere to OCHS values and principles.

Qualifications

Qualifications:

• BLS/CPR certification required.

• Minimum of 1–2 years of clinical nursing experience preferred, ideally in a primary care or community health setting.

• Experience or desire to work in team-based care model.

• Bachelor of Science or Associates in Nursing from an accredited school of nursing by AACN.

• Current Registered Nurse (RN) license from the Massachusetts State Board of Registration.

• Maintain and enhance professional nursing skills and knowledge by attending continuing education programs.

• Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting.

• Excellent written and verbal communication skills – bi-lingual helpful.

• Proficiency in computer skills including EPIC, Outlook, Microsoft office, OneDrive etc.

• Excellent judgment and ability to solve problems in a timely manner.

• Ability to adhere to strict confidentiality standards.

• Demonstrated ability to work effectively both as a team member and independently.

• Demonstrated ability to work in a culturally diverse and inclusive environment.

Work Environment

• The functions of this role are conducted remotely.

Other Duties Please note this job description is not designed to cover or contain a comprehensive list of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Reporting Structure: This position reports to the Director of Nursing AAP/EEO Statement Outer Cape Health Services is committed to a firm policy in favor of equal employment opportunity and will abide by all applicable state and federal regulations by not discriminating against any applicant or employee on the basis of race, religion, color, creed, sex, age, national origin, citizenship status, marital status, sexual orientation, gender identity and expression, disability or veteran status. Our commitment to equal employment opportunities shall include employment, upgrading, promotion, demotion, transfer, leaves or other absences from work, layoff, compensation and benefits, selection for training or other education, professional opportunities and conflict resolution. It is also the policy of OCHS to take affirmative action to employ and to advance in employment, all persons regardless of their status as woman, minority or individuals with disabilities or protected veterans, and to base all employment decisions only on valid job requirements. Please inform us of any necessary accommodations required during the application process and/or at any time during employment.   In accordance with Massachusetts law, we are committed to wage transparency. The salary range for this position is $35.00/hourly to $45.00/hourly. This range is provided to promote equity and transparency in our hiring process. Actual compensation may vary based on factors such as experience, qualifications, and other job-related criteria.