Value Based Care Nurse Care Manager

Job Description

Job Description

General Summary: The Value-Based Care Nurse Care Manager primarily supports Medicare patients and organizational goals by proactively identifying high-risk patients, closing care gaps, coordinating care, improving preventive and chronic disease management, and reducing avoidable healthcare utilization. This position uses population health data and EHR information to guide patient outreach, education, care coordination, and follow-up while collaborating with interdisciplinary teams to improve quality, patient outcomes, and Medicare value-based care performance. Responsibilities are performed within the individual's RN or LPN licensure and scope of practice.Essential Functions and Responsibilities: ●Manage an assigned Medicare population using data-driven approaches to identify high-risk patients, care gaps, and opportunities to improve quality, outcomes, and appropriate utilization.●Conduct proactive patient outreach, education, care planning, and follow-up to support preventive care, chronic disease management, and patient engagement.●Coordinate care transitions and follow-up following hospitalizations, emergency department visits, and other significant healthcare events.●Identify and support closure of Medicare quality and care gaps, including preventive screenings, immunizations, chronic disease monitoring, and Annual Wellness Visits.●Review patient records and population health data to identify clinical risks, care management needs, and opportunities for intervention and improved documentation.●Collaborate with providers and interdisciplinary teams to coordinate services, address barriers to care, and develop appropriate follow-up plans.●Utilize EHR, payer, ACO, and population health data to monitor performance, track interventions, and identify opportunities for improvement.●Support Medicare value-based care, ACO, and organizational quality initiatives through patient-centered interventions and continuous performance improvement.●Connect patients with appropriate healthcare, behavioral health, pharmacy, social, and community resources.●Maintain timely, accurate, and complete documentation of patient outreach, interventions, care coordination, and outcomes.●Review and work on assigned value-based care program reports to identify patient care opportunities, complete necessary follow-up, and support program goals.●Perform nursing and care management functions consistent with the individual's RN or LPN licensure and scope of practice, including assessment, education, outreach, care coordination, monitoring, documentation, and clinical decision-making, as applicable; obtain appropriate clinical oversight and escalate concerns that require additional assessment or intervention.●Support the Health Center's mission, vision, and values through active participation in organizational initiatives, community-related events, outreach activities, and other efforts that promote access to care and support the communities served.●Perform other duties as assigned.Qualifications:Required: ●Current, unrestricted Missouri RN or LPN license.●Graduate of an accredited nursing program.●Strong communication, organization, documentation, and patient engagement skills.●Ability to work independently and collaboratively within a multidisciplinary team, with appropriate escalation of clinical concerns.Preferred: ●CPR/BLS certification.●Experience in primary care, community health, care management, population health, or a related healthcare setting.●Experience with Medicare/Medicare Advantage, value-based care, ACOs, population health, quality improvement, or care management.●Experience using EHR and population health/analytics tools for care gap and high-risk patient identification.●Knowledge of risk stratification, utilization management, social determinants of health, and community resources.Performance Requirements:Knowledge: 1.Patient-centered care, population health, Medicare value-based care, chronic disease management, and quality improvement projects.2.Care coordination, care transitions, preventive care, healthcare utilization, and care gap management. 3.Clinical documentation, patient confidentiality, and applicable nursing scope of practice. 4.Understanding of Medicare quality measures, risk stratification, social determinants of health, and available community resources.  Skills1.Strong patient communication, engagement, education, and motivational support.2.Ability to assess patient needs, interpret clinical and population health data, identify care gaps, and support appropriate interventions.3.Ability to effectively coordinate care and collaborate with providers and interdisciplinary teams.4.Strong organizational, time management, documentation, and follow-up skills.5.Ability to effectively utilize EHR, population health, payer, and other technology and reporting tools to support patient care and program goals.Abilities1.Manage an assigned Medicare population to improve quality, outcomes, and appropriate utilization.2.Conduct patient outreach and support preventive care, chronic disease management, care transitions, and follow-up.3.Identify high-risk patients, care gaps, barriers, and opportunities for intervention.4.Work independently and collaboratively, with appropriate clinical escalation and documentation.5.Adapt to changing value-based care requirements, workflows, and organizational priorities.