Registered Nurse Care Manager – Value Based Care

Role Overview

• Provide clinical oversight to a POD of Medical Assistants and Health Coaches managing a cardiac patient panel.
• Ensure POD execution aligns with clinical protocols, care pathways, and value-based care objectives.
• Serve as the clinical escalation point for complex cases, ensuring timely intervention and appropriate level of care.
• Monitor POD performance, workload distribution, and adherence to program requirements.
• Lead regular care planning huddles to prioritize enrollments, engagement, and program completion.
• Collaborate with cardiology, primary care, post-acute providers, and community partners to align care plans with quality measures, risk-based contracts, and patient goals.
• Deliver end-to-end clinical care management, including triage, high-risk care management, and transitional care management for complex cardiac patients.
• Perform clinical triage of patient-reported symptoms, biometric alerts, and care gaps, escalating concerns per protocol to providers or emergency services as needed.
• Proactively identify clinical deterioration to prevent avoidable emergency department visits and hospitalizations.
• Lead high-risk care management for patients with advanced cardiac disease and multiple comorbidities through ongoing assessment and care planning.
• Conduct comprehensive assessments, medication reconciliation, and individualized, goals-based care plans.
• Address barriers to care such as medication adherence, social determinants of health, and access challenges in partnership with the care team.
• Provide patient and caregiver education on disease management, symptom recognition, and self-management strategies.
• Manage Transitional Care Management (TCM) following inpatient or post-acute discharge, including timely outreach, clinical assessment, and care coordination.
• Ensure timely follow-up, medication reconciliation, and patient education to support safe transitions of care and reduce readmissions.
• Document all interventions, care plans, and assessments accurately in Care Management system and the electronic medical record.
• Support reporting and performance improvement related to cardiac quality metrics, program key performance indicators and utilization outcomes.
• Contribute to continuous improvement initiatives aimed at improving outcomes, patient experience, and total cost of care.

Requirements

• Active, unrestricted Registered Nurse (RN) license
• Minimum 3–5 years of clinical nursing experience, preferably in cardiology, care management, or population health
• Experience working in value-based care, managed care, or risk-based contracts
• Strong clinical assessment and triage skills
• Demonstrated ability to work effectively within a multidisciplinary team

Benefits

• 401(k)
• Health insurance
• Dental insurance
• Vision insurance
• Disability insurance
• Life insurance