Registered Nurse Care Manager -Value Based Care (Must Reside in FL)

ABOUT: Cardiovascular Services of America (CVAUSA) is the largest private and independent cardiology network in the United States. Our inclusive and diverse network brings together top cardiovascular specialists and thought leaders who offer regional perspectives and a broad strategic vision for the future of patient care.

WHO WE ARE AND WHAT WE DO:
Headquartered in Orlando area, Cardiovascular Associates of America aims to bring the best cardiovascular physicians in one network with the common mission of saving lives, reducing costs, and improving patient care through clinical innovation. Through CVAUSA’s physician-centered practice management model, physicians drive clinical care and their practice culture, while benefiting from the business expertise and shared resources available through CVAUSA for better patient outcomes.

Novocardia, a division of CVAUSA, is on a mission to revolutionize cardiovascular care and empower clinicians across the United States to consistently deliver high-quality, prevention-focused, value-based, patient centered care. Chronic disease is the dominant cause of avoidable healthcare spending and death in the United States and worldwide. Fortunately, much of this disease burden and associated spending is potentially avoidable through delivery of more proactive, prevention-focused care. We are deeply passionate about improving care quality, and providing more Americans with access to great, evidence-based chronic disease
care.

JOB OVERVIEW:

The RN Care Manager provides clinical oversight and care management for a dedicated POD model staffed with Medical Assistants and Health Coaches, supporting cardiac patients under value-based agreements. This role is responsible for driving high-quality, cost-effective care through proactive clinical oversight, multidisciplinary collaboration, risk stratification, and care transitions.

The RN Care Manager serves as the clinical leader for the POD, ensuring care plans align with NCQA documentation requirements, contractual quality measures, and organizational performance goals. This role plays a critical part in risk mitigation, utilization management, and patient engagement across the continuum of care.

KEY RESPONSIBILITIES:

Clinical Oversight, POD Leadership & Care Coordination

 

• Provide clinical oversight to a POD of Medical Assistants and Health Coaches managing a cardiac patient panel.
• Ensure POD execution aligns with clinical protocols, care pathways, and value-based care objectives.
• Serve as the clinical escalation point for complex cases, ensuring timely intervention and appropriate level of care.
• Monitor POD performance, workload distribution, and adherence to program requirements.
• Lead regular care planning huddles to prioritize enrollments, engagement, and program completion.
• Collaborate with cardiology, primary care, post-acute providers, and community partners to align care plans with quality measures, risk-based contracts, and patient goals.

Clinical Program Execution & Management

• Deliver end-to-end clinical care management, including triage, high-risk care management, and transitional care management for complex cardiac patients.
• Perform clinical triage of patient-reported symptoms, biometric alerts, and care gaps, escalating concerns per protocol to providers or emergency services as needed.
• Proactively identify clinical deterioration to prevent avoidable emergency department visits and hospitalizations.
• Lead high-risk care management for patients with advanced cardiac disease and multiple comorbidities through ongoing assessment and care planning.
• Conduct comprehensive assessments, medication reconciliation, and individualized, goals-based care plans.
• Address barriers to care such as medication adherence, social determinants of health, and access challenges in partnership with the care team.
• Provide patient and caregiver education on disease management, symptom recognition, and self-management strategies.
• Manage Transitional Care Management (TCM) following inpatient or post-acute discharge, including timely outreach, clinical assessment, and care coordination.
• Ensure timely follow-up, medication reconciliation, and patient education to support safe transitions of care and reduce readmissions.

Documentation, Quality & Performance 

• Document all interventions, care plans, and assessments accurately in Care Management system and the electronic medical record.
• Support reporting and performance improvement related to cardiac quality metrics, program key performance indicators and utilization outcomes.
• Contribute to continuous improvement initiatives aimed at improving outcomes, patient experience, and total cost of care.

QUALIFICATIONS:

• Active, unrestricted Registered Nurse (RN) license
• Active compact RN license required. Possession of an active RN Illinois license is a PLUS
• Minimum 3–5 years of clinical nursing experience, preferably in cardiology, care management, or population health
• Experience working in value-based care, managed care, or risk-based contracts
• Strong clinical assessment and triage skills
• Demonstrated ability to work effectively within a multidisciplinary team

Skills & Competencies

• Clinical judgment and critical thinking
• Leadership and team facilitation
• Patient-centered communication
• Data-driven decision- making
• Adaptability in a fast-paced, outcomes-focused environment
• Commitment to high-quality, value-based care delivery

Work Environment

• Remote position requiring a dedicated, private workspace and reliable high-speed internet to ensure patient privacy and compliance with HIPAA standards.

Location: Remote near Orlando  Florida. 

Benefits:

• 401(k)
• Health insurance
• Dental insurance
• Vision insurance
• Disability insurance
• Life insurance

Novocardia provides equal employment opportunities {EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.

We are an equal opportunity employer and celebrate diversity. We are committed to creating an inclusive environment for all employees.