APRN – Medical Management (Value-Based Care)

Palm Medical Centers•Tampa, FL

About The Position

Palm Medical Centers is a rapidly growing, value-based primary care organization and a recognized leader in senior care across Florida, with over 30 locations and a 98% patient satisfaction rating. Our mission is to deliver personalized, preventative, and compassionate care while keeping patients healthier and out of the hospital. Our value-based model allows providers to spend more time with patients, focus on outcomes—not volume—and make a measurable impact on quality of life. Position Summary The APRN – Medical Management role is a hybrid clinical leadership and care coordination position designed to reduce hospital admissions, readmissions, and avoidable SNF utilization through proactive medical management, care transitions, and interdisciplinary collaboration. This APRN will work closely with PCPs, Medical Directors, case management, and external facilities to ensure high-risk patients receive timely, coordinated, and appropriate care across settings.

Requirements

Active, unrestricted Florida APRN license
DEA license or eligible to obtain within 60 days of hire
2–3+ years of experience in primary care, geriatrics, or internal medicine
Experience in value-based care, Medicare Advantage, Medicare, and/or Medicaid populations
Strong knowledge of chronic disease management, preventative care, and quality metrics
Excellent communication, organization, and problem-solving skills

Nice To Haves

Background in case management, utilization management, or care coordination
Familiarity with InterQual or Milliman Care Guidelines
Prior RN case management or clinical coordination experience
Bilingual (Spanish/English)

Responsibilities

Provide advanced clinical oversight for high-risk and complex patients in a value-based primary care model
Perform medical management for patients with frequent hospitalizations, chronic disease burden, or care gaps
Support PCPs with care planning, post-discharge follow-up, and escalation of care needs
Assist with direct hospital admissions, SNF placement, and discharge planning when clinically appropriate
Monitor and manage length of stay (LOS) for hospital and nursing home patients
Track daily hospital and nursing home admissions, discharges, and transfers
Coordinate transitions of care to reduce readmissions and adverse outcomes
Obtain weekly updates on nursing home patients and communicate changes to internal teams
Identify potential catastrophic, stop-loss, or high-cost cases
Support subrogation and cost-allocation identification as needed
Lead or participate in interdisciplinary case conferences and care reviews
Communicate with patients, families, hospitals, SNFs, and community resources
Advocate for medically necessary services, diagnostics, and follow-up care
Coordinate transportation, community services, and ancillary resources
Evaluate workflows, utilization patterns, and care processes to improve outcomes
Support quality initiatives tied to Medicare Advantage, Medicare, and Medicaid metrics
Contribute to policy, procedure, and workflow redesign
Provide education and guidance to clinical staff to improve care coordination competency
Maintain accurate, timely clinical and utilization documentation in the EMR (eCW preferred)
Ensure compliance with value-based care requirements, payer guidelines, and regulatory standards
Apply knowledge of CPT, ICD-10, and utilization review principles