Registered Nurse Care Manager – Value Based Care

🕒 3 dias atrás

🐊 Florida – Remoto

🐊 Florida – Remote

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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Cardiovascular Associates of America - CVAUSA

SiteLinkedInTodas as Vagas

51 - 200 funcionários

Fundada em 2021

Sediada em Orlando, a Cardiovascular Associates of America tem como objetivo reunir os melhores médicos cardiovasculares em uma rede com a missão comum de salvar vidas, reduzir custos e melhorar o atendimento ao paciente por meio de inovação clínica. Através do modelo de gestão de práticas centrado no médico da CVAUSA, os médicos conduzem o cuidado clínico e a cultura de suas práticas, enquanto se beneficiam da expertise empresarial e dos recursos compartilhados disponíveis através da CVAUSA.

Descrição

• 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. • 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. • 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.

🎯 Requisitos

• Active, unrestricted Registered Nurse (RN) license • 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

🏖️ Benefícios

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