Registered Nurse (1942)

US Heart & Vascular•Birmingham, AL

2d•Onsite

About The Position

US Heart and Vascular is seeking a Care Management RN to join our Value Based Care Management team in Birmingham, AL Position Summary The Embedded RN Care Manager is a key member of the cardiovascular care team, working onsite within designated practices to proactively support patients with chronic cardiovascular conditions. This role blends direct patient interaction, care coordination, disease education, transitional care support, and population health management. The Embedded RN partners closely with cardiologists, APPs, clinic staff, and the Virtual Care Team to ensure patients receive timely, continuous, and comprehensive care. This role directly supports Value-Based Care by improving outcomes, reducing avoidable hospitalizations, and enhancing patient experience.

Requirements

Knowledge, Skills & Abilities: Strong clinical judgment and critical thinking skills.
Ability to manage multiple priorities and function independently in a fast-paced environment.
Excellent communication and interpersonal skills with patients, caregivers, and clinical teams.
Knowledge of cardiovascular disease processes (HF, HTN, Afib, CAD, dyslipidemia).
Familiarity with population health, chronic care management, and transitional care principles.
Competence in basic cardiovascular technology (EKG interpretation, vital signs, diagnostics).
Minimum Requirements: Graduate of an accredited nursing program (ADN or BSN).
Active, unrestricted RN license in the state of employment.
Current BLS certification.
Minimum 2 years of clinical nursing experience; cardiology or chronic care management preferred.
Experience in outpatient, ambulatory, or care management setting preferred.

Nice To Haves

Preferred Qualifications: Experience with RPM, CCM, PCM, or TCM programs.
Experience in Value-Based Care models or population health initiatives.

Responsibilities

Clinical Care & Chronic Disease Management Conducts patient assessments including medical history, SDOH, medication review, and symptom evaluation.
Develops and updates individualized care plans.
Provides education on cardiovascular conditions, medications, symptom monitoring, and lifestyle changes.
Reviews RPM data, diagnostics, and labs; escalates concerning findings to providers.
Care Coordination Manages care transitions, including post-discharge follow-up and scheduling.
Closes clinical care gaps and supports preventive care needs.
Serves as liaison between patients, providers, APPs, Virtual Care, and community resources.
Facilitates interdisciplinary communication to ensure continuity of care.
Embedded Workflow Responsibilities Performs proactive outreach for patients enrolled in ICC, RPM, CCM, PCM, and TCM programs.
Introduces care management services and documents consent and enrollment in the EMR.
Triages patient messages and calls using evidence-based protocols.
Participates in daily/weekly huddles with the clinic team to identify patient needs.
Identifies high-risk patients for early intervention and escalates concerns appropriately.
Performs panel management activities for a population of up to 1,500 patients, using risk-stratification tools to prioritize outreach, identify rising-risk patients, close care gaps, and ensure timely follow-up.
Direct Patient Care (As applicable to clinic workflow) Performs skilled assessments, including in-person evaluations and vital sign reviews.
Conducts medication reconciliation and adherence support.
May administer IV diuretics and monitor response when part of an outpatient HF protocol.
Documentation & Compliance Ensures accurate, timely EMR documentation in alignment with CMS and organizational guidelines for CCM, PCM, RPM, and TCM.
Maintains care plans, logs, and billing support documentation.