RN Care Manager, Population Health Programs

Duet•New York, NY

2d•$85,000 - $110,000•Hybrid

About The Position

RN Care Manager, Population Health Programs at Duet About Duet : Duet is on a mission to transform primary care by empowering nurse practitioners (NPs) to own and operate their practices. By providing NPs with tailored products and services within a supportive setting, Duet is building the nation’s largest network of NP-owned practices, driving better outcomes for patients and communities. Role Overview The Registered Nurse Care Manager (RNCM) will be the founding clinical hire for our Medicare care management programs. This is an opportunity to help design, operationalize, and scale a best-in-class value-based care management model from the ground up. The RNCM will deliver longitudinal, relationship-based care to Medicare beneficiaries while also partnering closely with leadership to build workflows, define best practices, and shape the future of the program. This role blends hands-on clinical care management with operational leadership and program development. This position is ideal for an RN who is entrepreneurial, systems-oriented, and excited to build a care management playbook.

Requirements

Active RN license (New York State)
3+ years of clinical nursing experience (primary care, care management, population health, or related field preferred)
Experience working with Medicare populations strongly preferred
Demonstrated ability to build or improve clinical workflows
Strong operational mindset with comfort in ambiguity and early-stage environments
Familiarity with value-based care models (ACO, MSSP, APCM, CCM)
Strong care coordination, documentation, and patient engagement skills
Comfortable working in a hybrid NYC-based role with in-person collaboration
Knowledge of social determinants of health and community-based resources

Responsibilities

Conduct comprehensive assessments for Medicare beneficiaries, including medical, behavioral, and social needs
Develop and manage individualized care plans aligned with evidence-based guidelines
Provide chronic condition management (e.g., diabetes, CHF, COPD, hypertension)
Perform medication reconciliation and adherence support
Deliver patient education, coaching, and self-management support
Coordinate care across primary care, specialists, hospitals, post-acute, and community resources
Manage transitions of care following ED visits or hospitalizations
Close care gaps related to preventive care, screenings, and quality measures
Design and refine care management workflows from enrollment through ongoing engagement
Build documentation standards to support APCM and other care management billing programs
Partner with analytics and operations to define caseload models, outreach triggers, and performance metrics
Identify gaps in process and implement scalable solutions
Help select and optimize care management tools and EHR workflows
Contribute to hiring plans, onboarding materials, and training content as the team grows
Serve as a clinical thought partner to leadership on ACO and value-based strategy
Support ACO quality and utilization goals (HEDIS, STARs, TCM, etc.)
Document care management activities to support billing (e.g., APCM / care management programs)
Identify opportunities to reduce avoidable ED visits and hospital admissions
Partner with operations and analytics teams to track outcomes and performance
Serve as a core member of the interdisciplinary care team
Communicate regularly with patients, caregivers, and providers via phone and video settings
Escalate clinical concerns appropriately and support clinical decision-making