Registered Nurse Care Manager – Value Based Care
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Job Description
RN Care Manager providing clinical oversight and management for cardiac patients in a value-based care model. Leading a team of Medical Assistants and Health Coaches for improved patient outcomes.
Responsibilities:
- 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
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