Care Manager, CMHN MSSP ACO Care Management Program

North Carolina Community Health Center Association•Raleigh, NC

10d

About The Position

The Care Manager, CMHN MSSP ACO Care Management Program, is responsible for designing, implementing, and optimizing Carolina Medical Home Network’s Medicare Shared Savings Program (MSSP) ACO Care Management Program. The role supports participating health centers in improving quality outcomes, reducing total cost of care, enhancing patient experience, and delivering sustainable care management services. The Care Manager collaborates with ACO leadership, participating health centers, organizational teams, vendors, and community partners to develop and operate the program’s clinical and operational infrastructure. The care management delivery model is being determined and may involve CMHN staff, an external vendor, or a hybrid approach. Responsibilities may shift among direct patient care, workflow and process development, and external partner coordination as the program evolves. The position works closely with CMHN’s Medicaid care management programs while maintaining distinct Medicare program objectives, workflows, and regulatory requirements. As the program grows, the Care Manager supports recruitment, onboarding, supervision, and professional development of care management staff. The role may involve Medicare care management services such as Chronic Care Management, Advanced Primary Care Management, Transitional Care Management, Principal Care Management, Remote Patient Monitoring, Behavioral Health Integration, and the Collaborative Care Model. It also includes direct care management for high-risk and high-need beneficiaries, program monitoring and quality improvement, compliant documentation and billing workflows, staff oversight, and travel to participating health centers throughout North Carolina as needed. The position may work remotely as defined by health center or NCCHCA policy and requires an operational automobile, current active North Carolina driver’s license, and auto insurance.

Requirements

Associate degree or higher from an accredited School of Nursing.
Current Registered Nurse (RN) license in North Carolina.
At least three years of experience providing care management, case management, or care coordination to a safety-net population.
Up-to-date required immunizations: Hepatitis B, MMR, Varicella, Tdap, annual flu vaccine, and TB skin test.
BLS (CPR).
Excellent written and oral communication skills and ability to communicate clearly and succinctly.
Proficiency with Microsoft Outlook, Word, Excel, PowerPoint, and email.
Strong time management, organization, prioritization, accuracy, and ability to manage multiple tasks efficiently.
Ability to work flexibly in a developing program where roles, workflows, and priorities may change.
Working knowledge of, or willingness to learn, Medicare care management services and documentation and billing requirements.
Ability to use claims, attribution, utilization, and quality data for patient identification and program monitoring.
Ability to learn and work across multiple EHRs, documentation platforms, and population health tools.
Ability to build effective working relationships with health center staff, community organizations, vendors, and other external partners.
Demonstrated supervisory and management skills, including coaching, delegation, performance monitoring, and staff development.
Strong conflict resolution, de-escalation, critical-thinking, and problem-solving skills; ability to balance empathy with professional boundaries.
Ability to maintain accurate caseload tasks and documentation and to mentor staff in productivity and work quality.
Current active North Carolina driver’s license, auto insurance, and an operational automobile.
Ability to meet the physical demands of the role, including standing, sitting, talking, hearing, computer and telephone use, reaching, stooping, kneeling, light to moderate lifting, and tolerating travel.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Experience working with Medicare populations or value-based care models.
Experience leading projects, implementing workflows, or supporting program development.
Certified Case Manager (CCM); willingness to complete certification within one year of starting the position.
Experience with accountable care organizations, the Medicare Shared Savings Program, Medicare populations, or other value-based care models.
Supervisory or managerial experience.

Responsibilities

Support and help lead development, implementation, and ongoing optimization of the CMHN MSSP ACO Care Management Program.
Develop and implement standardized policies, procedures, workflows, clinical protocols, documentation standards, operational processes, and implementation plans.
Evaluate and support Medicare care management services, including CCM, APCM, TCM, PCM, RPM, BHI, CoCM, and other appropriate CMS-approved services.
Support participating health centers with program adoption, workflow redesign, change management, training, and technical assistance.
Evaluate internal, vendor-supported, and hybrid care management delivery models and support vendor implementation and integration as applicable.
Collaborate with health centers to identify high-risk populations and improve care coordination, quality, utilization, and patient outcomes.
Develop patient-centered, team-based care management processes and comprehensive assessments addressing medical, biopsychosocial, behavioral, spiritual, and cultural needs.
Use claims, utilization, attribution, quality, and other population health data to identify beneficiaries who may benefit from intervention and to monitor program performance.
Support MSSP quality performance through care-gap identification and closure, patient outreach, coordination, and follow-up.
Develop and implement compliant documentation, operational, and billing workflows for Medicare care management services.
Collaborate with finance, operations, health centers, vendors, and other partners to support reimbursement and program sustainability.
Monitor program quality, productivity, patient outcomes, utilization, financial performance, return on investment, and operational metrics; recommend continuous improvements.
Develop and use dashboards, reports, and performance metrics; participate in quality improvement initiatives and support health centers in achieving MSSP goals.
Develop and oversee quality assurance processes to ensure consistent, compliant, high-quality care management.
Provide clinical guidance to participating health centers and collaborate with organizational leadership and departments on program implementation.
Recruit, onboard, train, mentor, supervise, and support professional development of Care Managers, Care Coordinators, and other assigned staff.
Provide day-to-day supervision, coaching, feedback, and performance support; conduct regular one-on-one meetings and monthly performance reviews as applicable.
Monitor staff productivity, quality, documentation, workflow adherence, and performance; maintain staff performance documentation and support improvement plans when needed.
Delegate work appropriately according to staff roles, licenses, and certifications; support staff in working at the top of their license or certification.
Provide clinical oversight of external care management partners, as applicable, and foster partnerships with community organizations and healthcare providers.
Deliver direct care management to high-risk and high-need beneficiaries, including assessment, care planning, coordination, education, and follow-up.
Work with patients and caregivers to identify behavioral, social, cultural, and environmental strengths and barriers related to diagnoses, treatment, and access to care.
Develop and implement patient-centered care plans and interventions using motivational interviewing, strengths-based, and solution-focused approaches; establish SMART goals with patients and families.
Educate patients and families about diagnoses, medications, resources, prevention, risk factors, and self-management.
Serve as an advocate and liaison among patients, families, community services, primary care providers, specialists, and other care team members.
Maintain accurate and timely caseload and care management documentation in applicable platforms and comply with privacy, security, HIPAA, CMS, and other legal requirements.
Travel to participating health centers throughout North Carolina as needed for implementation, training, operations, and coordination with clinic-based care teams, patients, and families.
Attend departmental and corporate meetings, training, and other required events; perform other duties as assigned.