Value Based Care R.N. - Capitated Business

Hollywood Presbyterian•Los Angeles, CA

15d

About The Position

Position Summary: The Value Based Care R.N. for Capitated Programs is responsible for coordinating and managing patient care within capitated and risk-based contract environments. This role focuses on ensuring quality, cost-effective, and clinically appropriate care for members by partnering with our MSO partners to conduct assessments, develop care plans, coordinate services, and collaborate with providers across the continuum of care. The Value Based Care R.N. ensures compliance with clinical guidelines, regulatory requirements, and delegated risk arrangements while driving optimal outcomes for members and contracted partners.

Requirements

Bachelor of Science in Nursing
5 years of clinical experience in acute care, home health, case management, or related field.
Understanding of capitated and delegated risk models.
Knowledge of managed care, utilization management, and care coordination.
Proficiency with MCG, InterQual, and case management software.
Excellent communication, assessment, and critical‑thinking skills.
Ability to manage multiple priorities and meet performance targets.
California RN license
Current Los Angeles County Fire Card (or must be obtained within 30 days of hire)
Assault Response Competency (ARC) required (within 30 days of hire)

Nice To Haves

Experience in capitated, managed care, ACO, IPA, or value‑based care settings preferred

Responsibilities

Work with MSO partners and physicians to conduct comprehensive clinicalassessments for members in capitated programs to ensure appropriate level ofcare, length of stay management and repatriation of member who are out ofnetwork.
Assist MSO Partners with coordinating services including specialist referrals, homehealth, DME, social services, and community resources.
Monitor member progress and update care plans as needed.
Prevent avoidable ER visits, hospitalizations, and readmissions.
Evaluate medical necessity using clinical criteria such as InterQual or MCG.
Support utilization optimization within capitated and risk-bearing arrangements.
Collaborate with Contracted IPA’s /MSOs to manage high-risk cases and ensureappropriate site-of-care decisions.
Monitor utilization trends and identify opportunities for improvement.
Serve as a liaison between Hospital and, MSO’s, physicians, , and ancillary providers.
Ensure coordinated and effective care delivery across all stakeholders.
Partner with MSO’s, Providers and care teams to support delegated or capitatedworkflows.
Document all activities accurately in care management systems.
Maintain compliance with Medicare, Medicaid, commercial regulations, and NCQA standards.
Adhere to delegated risk agreements and reporting requirements.
Participate in audits, quality reviews, and process improvement initiatives.