Registered Nurse (RN) - Care Manager, Value Based Programs (Full-Time, M-F)
About The Position
The role of the Value-Based Care Manager reports to the Director of Value-Based Programs. This position is responsible for supporting value-based care initiatives within primary care clinics, ensuring high-quality patient outcomes, efficient care coordination, and alignment with performance-based reimbursement models. This position works collaboratively with providers, care teams, coding, and leadership to implement workflows that improve patient care, identify and close care gaps, and enhance clinic performance in quality and cost metrics.
Requirements
- Graduate of an accredited nursing program.
- Unencumbered registered nursing license and CPR required.
Nice To Haves
- Previous clinic system experience and value-based programs, population health, or quality improvement preferred.
Responsibilities
- Assess patients' needs, both physical and psychosocial, and develop individualized care plans to address those needs.
- Conduct care management calls to identify and follow-up on care gaps, long-term care management, ER visits, and inpatient stays.
- Perform medication reconciliation and assist in chronic disease management.
- Provide education and support to patients and their families, empowering them to actively participate in their care and manage their health condition, including education for self-management strategies, preventive care, and treatment adherence.
- Facilitate transitional care management (TCM) for recently discharged patients.
- Perform other care and assessment activities as needed, including Medicare annual wellness visits.
- Monitor and report on key quality measures, including HEDIS, Medicare Advantage Star Ratings, ACO benchmarks.
- Partner and collaborate with clinic leadership and providers to implement workflows that optimize value-based care performance.
- Assist in identifying care gaps and developing strategies to improve patient outcomes.
- Participate in risk stratification and population health initiatives to identify high-risk patients.
- Serve as the primary source of value-based care data for the clinic, ensuring accurate reporting and performance tracking.
- Analyze clinic-level quality data to identify trends, root causes, and areas for improvement.
- Provide ongoing updates to clinic staff on progress toward value-based goals and best practices.
- Manage and maintain patient charts and upload information into payor portals.
- Conduct regular clinic meetings to inform staff about performance metrics and value-based initiatives.
- Implement workflows that align with value-based contracts and population health measures and provide ongoing education and training to clinic staff, physicians, and leadership ensuring efficiency and effectiveness of care team.
- Support front-office and clinical staff in understanding value-based care documentation and coding.
- Actively participate in interdisciplinary team meetings.
- Facilitate quality improvement projects aligning with areas of improvement, using PDSA cycles.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
501-1,000 employees
