RN Care Manager, Population Health Programs
Duet
full-time
Posted on:
Location Type: Hybrid
Location: New York City • New York • United States
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Salary
💰 $85,000 - $110,000 per year
About the role
- 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
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
Benefits
- Health insurance
- Retirement plans
- Flexible work arrangements
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
chronic condition managementmedication reconciliationcare management workflowsdocumentation standardscare management billingperformance metricsEHR workflowsclinical workflowspatient educationself-management support
Soft Skills
care coordinationpatient engagementoperational mindsetcommunicationteam collaborationproblem-solvingleadershipadaptabilitycoachinginterpersonal skills
Certifications
Active RN licenseNew York State RN license