Registered Nurse Care Manager -Value Based Care (Must Reside in FL)

Cardiovascular Associates of America•, FL

3d•Remote

About The Position

The RN Care Manager provides clinical oversight and care management for a dedicated POD model staffed with Medical Assistants and Health Coaches, supporting cardiac patients under value-based agreements. This role is responsible for driving high-quality, cost-effective care through proactive clinical oversight, multidisciplinary collaboration, risk stratification, and care transitions. The RN Care Manager serves as the clinical leader for the POD, ensuring care plans align with NCQA documentation requirements, contractual quality measures, and organizational performance goals. This role plays a critical part in risk mitigation, utilization management, and patient engagement across the continuum 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
Clinical judgment and critical thinking
Leadership and team facilitation
Patient-centered communication
Data-driven decision-making
Adaptability in a fast-paced, outcomes-focused environment
Commitment to high-quality, value-based care delivery

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.