Care Manager, CMHN MSSP ACO Care Management Program

Minimum Qualifications (Degrees/Certificates)

• Associate degree or better from an accredited School of Nursing; Bachelor of Science in Nursing (BSN) preferred.
• Licensed as a Registered Nurse (RN) with the state of NC.
• At least three years of experience providing care management, case management, or care coordination to a safety-net population.
• Experience working with Medicare populations or value-based care models preferred.
• Experience leading projects, implementing workflows, or supporting program development preferred.
• Certified Case Manager (CCM) Preferred/Willingness to complete within one year of starting position.
• Experience with accountable care organizations, Medicare Shared Savings Program (MSSP), Medicare populations, or other value-based care models preferred.
• Supervisory or managerial experience preferred, not required
• Up to Date on required immunizations (See list below)
  • Hepatitis B
  • MMR
  • Varicella
  • Tdap
  • TB skin test
  • Flu vaccine (annually)
  • BLS (CPR)

Knowledge, Skills, and Abilities 

• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use, and e‐mail communication.
• Ability to communicate clearly and succinctly.
• Dependable, manages time well; efficient and organized.
• Ability to produce accurate work; ability to perform multiple tasks in a proficient and timely manner.
• Demonstrate good supervisory and management skills.
• Flexibility and comfort working in a developing program where roles, workflows, and priorities may change.
• Working knowledge of, or willingness to learn, Medicare care management services and their documentation and billing requirements.
• Ability to use claims, attribution, utilization, and quality data to support patient identification and program monitoring.
• Ability to learn and work across multiple EHRs, documentation platforms, and population health tools.
• Ability to build effective working relationships with health center staff, community organizations, and external partners, including vendors.

Supervisory Responsibilities

• Provides day-to-day supervision, guidance, and support to assigned ACO Care Coordinator(s) and other care management staff as applicable.
• Conducts regular one-on-one meetings, provides coaching and feedback, and supports staff development and performance improvement.
• Monitors staff productivity, quality, documentation, and adherence to established care management workflows and program expectations.
• Supports onboarding, training, competency development, and ongoing education for assigned staff.
• Identifies performance concerns and areas for improvement and works with leadership and Human Resources, as appropriate, to address them.
• Promotes effective delegation and ensures staff work at the appropriate level of their role, license, or certification.

Essential Functions

• Support and help lead the development, implementation, and ongoing optimization of the CMHN MSSP ACO Care Management Program in collaboration with ACO leadership and participating health centers.
• Develop and implement standardized policies, procedures, workflows, clinical protocols, documentation standards, and operational processes based on the care management model selected by the ACO.
• Evaluate, support, and implement Medicare care management services, which may include Chronic Care Management (CCM), Advanced Primary Care Management (APCM), Transitional Care Management (TCM), Principal Care Management (PCM), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), Collaborative Care Model (CoCM), and other CMS-approved care management services as appropriate.
• Develop implementation plans and support participating health centers through program adoption, workflow redesign, and change management.
• Identify opportunities to improve patient outcomes, quality performance, operational efficiency, and financial sustainability.
• Participate in the evaluation of internal, vendor-supported, or hybrid care management models. Depending on the model selected, this may include developing internal policies, workflows, and procedures; supporting vendor implementation and integration with CMHN and participating health centers; or both.

• Collaborate with participating health centers to identify high-risk patient populations and develop strategies to improve care coordination, quality, and utilization.
• Develop standardized care management processes that promote patient-centered, team-based care.
• Monitor care management quality, productivity, patient outcomes, and operational performance through regular review of program metrics.
• Collaborate with clinical leadership to ensure care management services align with MSSP quality initiatives and organizational priorities.
• Develop educational materials and provide training and technical assistance to participating health centers.
• Develop, review, and complete comprehensive assessments that are patient-centered and considers the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual, and cultural needs of the enrolled population, throughout the continuum of care to improve their health outcomes.
• Use available ACO claims, utilization, attribution, quality, and other population health data to identify and prioritize beneficiaries who may benefit from care management intervention.
• Support participating health centers in improving MSSP ACO quality performance through identification and closure of care gaps, patient outreach, care coordination, and follow-up.

• Support the development and implementation of compliant documentation, operational, and billing workflows for Medicare care management services, in collaboration with ACO leadership, participating health centers, vendors, and other partners as applicable.
• Collaborate with finance, operations, and participating health centers to optimize reimbursement and program sustainability.
• Monitor program performance, utilization, quality outcomes, and return on investment, making recommendations for continuous improvement
• Develop and oversee quality assurance processes to ensure consistent, compliant, and high-quality care management services.

• Develop and utilize dashboards, reports, and performance metrics to monitor program effectiveness.
• Analyze quality, utilization, financial, and operational data to identify improvement opportunities.
• Participate in quality improvement initiatives and support participating health centers in achieving MSSP performance goals.

• Serve as a clinical resource to participating health centers regarding Medicare care management services and best practices.
• Collaborate with the Chief Medical Officer, Vice President of Care Management and Provider Network Support, organizational departments, and participating health centers to support successful program implementation.
• Assist with recruitment, onboarding, training, mentoring, and supervision of Care Managers and Care Coordinators as the program expands.
• Foster collaborative relationships with community organizations and healthcare partners to support patient care and care transitions.
• Collaborate with and provide clinical oversight of external care management partners, as applicable, to support integration with participating health centers and alignment with ACO clinical, quality, and cost goals.

• Provide direct care management services as the MSSP ACO program is developed and implemented, including management of high-risk and high-need beneficiaries identified through ACO data and participating health center referrals. Collaborate with patients/caregivers to identify and address behavioral, social, cultural, and environmental strengths and barriers as it relates to his/her diagnosis, treatment, and access to care.
• Implement Care Management interventions, set goals, and develop the plan of care based on transitional care discharge plans/instructions, comprehensive assessment, and patients’ goals.
• Implement patient-centered plans using therapeutic skills and techniques such as motivational interviewing, strengths-based, and solution-focused modalities.
• Facilitate and provide education to patient/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management.
• Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients’ and families' identified goals.

• Travel to participating health centers throughout North Carolina as needed to support implementation, training, and program operations.
• Maintain compliance with all organizational policies, HIPAA requirements, CMS regulations, and applicable federal and state laws.
• Perform other duties as assigned.

• This could include, but is not limited to, maintaining performance documentation on staff (completion of audits), identifying high performance staff, identifying clear areas for improvement & assisting with creating plans, if corrective action is needed, and meeting with staff monthly for 1:1 performance review.

• Including mentoring/ supporting other Care management staff in maintaining and monitoring their productivity.

• Ability to find, utilize, and share resources with team members.
• Demonstrate ability to support clients/team with needs in Care Management and understand when and where support is needed.
• Provide consultation with team on complex cases, as needed.

• Oversight of Care Management services, quality and activities based on care management standards of practice for enrolled populations.
• Delegates tasks and referrals to members of the care management team appropriately, accurately, and timely according to established workflows.
• Serve as an advocate and liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services.
• Collaborate with multi-disciplinary team members to facilitate achievement of desired health outcomes.
• Maintain appropriate and timely documentation on the Care Management documentation platform, in accordance with organizational policies and procedures.
• Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization.
• Adhere to NCCHCA privacy and security policies to ensure that patient and network data are properly safeguarded.
• Abide by department guidelines, company policies, and HIPAA regulations.
• Attend departmental and corporate meetings, local and regional training, or other events as required.
• Willingly perform other duties as assigned.
• Will go on-site to health centers as needed to coordinate with the clinic-based care team and/or patient and family.
• Support organizational goals and objectives in meeting performance improvement targets for various initiatives, programs, and standards of care.
• Review care management productivity and clinical performance data to assess and support care management priorities and determine appropriate interventions.
• Ensure standardized plans of care expectations and team development to ensure standards related to assessment and care plan standards and organizational and team goals are met.
• Manage and supervise team members to ensure work is done timely and accurately. All staff work at the top of their license/certification.

Physical Demands

• While performing the duties of this job, the employee is regularly required to stand, sit, talk, hear, and use hands and fingers to operate a computer and telephone keyboard, reach, stoop, and kneel.
• Specific vision abilities required by this job include close vision requirements due to computer work and distant vision requirements.
• Light to moderate lifting is required.
• Ability to uphold the stress of traveling.
• Regular, predictable attendance is required.

Work Environment 

• Moderate noise (i.e., business offices with computers, phone, and printers, light traffic).
• Ability to work in a confined area.
• May work remotely as defined by the health center or NCCHCA policy.
• Ability to sit at a computer terminal for an extended period or drive distances.
• Must have an operational automobile and current active NC driver’s license and auto insurance.