RN Care Manager, Population Health Programs

Role Overview

• Conduct comprehensive assessments for Medicare beneficiaries, including medical, behavioral, and social needs
• Develop and manage individualized care plans aligned with evidence-based guidelines
• Provide chronic condition management (e.g., diabetes, CHF, COPD, hypertension)
• Perform medication reconciliation and adherence support
• Deliver patient education, coaching, and self-management support
• Coordinate care across primary care, specialists, hospitals, post-acute, and community resources
• Manage transitions of care following ED visits or hospitalizations
• Close care gaps related to preventive care, screenings, and quality measures
• Design and refine care management workflows from enrollment through ongoing engagement
• Build documentation standards to support APCM and other care management billing programs
• Partner with analytics and operations to define caseload models, outreach triggers, and performance metrics
• Identify gaps in process and implement scalable solutions
• Help select and optimize care management tools and EHR workflows
• Contribute to hiring plans, onboarding materials, and training content as the team grows
• Serve as a clinical thought partner to leadership on ACO and value-based strategy
• Support ACO quality and utilization goals (HEDIS, STARs, TCM, etc.)
• Document care management activities to support billing (e.g., APCM / care management programs)
• Identify opportunities to reduce avoidable ED visits and hospital admissions
• Partner with operations and analytics teams to track outcomes and performance
• Serve as a core member of the interdisciplinary care team
• Communicate regularly with patients, caregivers, and providers via phone and video settings
• Escalate clinical concerns appropriately and support clinical decision-making

Requirements

• Active RN license (New York State)
• 3+ years of clinical nursing experience (primary care, care management, population health, or related field preferred)
• Experience working with Medicare populations strongly preferred
• Demonstrated ability to build or improve clinical workflows
• Strong operational mindset with comfort in ambiguity and early-stage environments
• Familiarity with value-based care models (ACO, MSSP, APCM, CCM)
• Strong care coordination, documentation, and patient engagement skills
• Comfortable working in a hybrid NYC-based role with in-person collaboration
• Knowledge of social determinants of health and community-based resources

Benefits

• Health insurance
• Retirement plans
• Flexible work arrangements
• Professional development opportunities