Care Manager - USFTGP UMSA Quality and Safety

Academic Medical Group Inc; Tampa (FL); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Academic Medical Group Inc. is seeking a Care Manager to support high‑risk patients in ambulatory settings, collaborating with multidisciplinary teams to close care gaps and optimize population health outcomes.

The role blends remote and on‑site work, emphasizing health coaching, chronic care management, and effective care transitions. Ideal candidates will have an Associate’s Degree in Nursing, RN licensure, and 5+ years in healthcare, with proficiency in Epic or Cerner and strong communication

Qualifications

• Associate’s degree in nursing and RN licensure required.
• Experience in chronic care management or case management preferred.
• Knowledge of chronic disease guidelines, care coordination, and social determinants of health.

Responsibilities

• Assess high-risk patients via AWVs and CCM evaluations to identify care gaps.
• Provide clinical health coaching to support self-management of chronic conditions.
• Evaluate social determinants of health and connect patients to resources to reduce risks.
• Develop individualized multidisciplinary plans of care to prevent avoidable events.
• Coordinate transitions of care with referrals and follow-ups.
• Collaborate with PCP offices, ACO partners, and managed care staff on population health goals.
• Apply risk adjustment to stratify patient panels.
• Document in the EHR and maintain productivity.
• Use motivational interviewing to support health behaviors.
• Work remotely and on-site with care teams.

Skills

Chronic disease management

Risk stratification

Care coordination

Motivational interviewing

EHR proficiency

Communication skills

Education

Associate’s Degree Nursing

Tools

Epic

Cerner

Job description

Job Description - Care Manager - USFTGP UMSA Quality and Safety (260004I8)

Job Description

Care Manager - USFTGP UMSA Quality and Safety - ( 260004I8 )

Description

The Care Manager supports high‑risk patients across the continuum of care by serving as a primary point of contact for patients and their multidisciplinary care teams. This role focuses on improving outcomes for patients in the ambulatory setting by identifying gaps in preventive and chronic disease management, reducing avoidable acute care utilization, and implementing individualized care plans. Working closely with USFTGP's physician offices, the Care Manager optimizes quality performance, risk adjustment processes, and overall population health management. The position may include conducting health coaching, chronic care management, Annual Wellness Visits, behavioral interviewing, and care transitions while collaborating with Accountable Care Organization (ACO) and value based care initiatives, managed care partners, and community resources. The Care Manager functions autonomously, maintains strong communication and organizational skills, and provides an exceptional patient experience while working both remotely and on‑site as needed.Essential Functions

• Assess high‑risk patients by performing Annual Wellness Visits (AWVs), chronic care management evaluations, and needs assessments to identify care gaps and risk factors.
• Provide clinical health coaching to support patient self‑management of chronic conditions, lifestyle changes, and adherence to treatment plans.
• Evaluate social determinants of health and connect patients to community resources to reduce health risks and improve outcomes.
• Implement individualized, multidisciplinary plans of care to prevent avoidable emergency department visits, hospitalizations, and disease progression.
• Coordinate transitions of care, ensuring timely referrals, follow‑up appointments, and communication with ancillary providers and community agencies.
• Collaborate with primary care offices, ACO partners, and managed care staff to align with value‑based payment models and organizational population health goals.
• Utilize risk adjustment principles to stratify patient panels and manage high‑risk populations effectively and efficiently.
• Maintain thorough and timely documentation in the electronic health record and meet all productivity and performance expectations.
• Use behavioral interviewing and active listening techniques to understand patient concerns, reduce resistance, and support positive health behaviors.
• Work autonomously within remote and in‑person settings, maintaining strong communication with the provider care team, leadership, and partners across the continuum of care.

Qualifications Education Qualifications

• Associate’s Degree Nursing

Licenses and Certifications

• Registered Nurse
• Ambulatory Care Nursing
• Case Management Certification
• Certified Professional in Healthcare Quality

Experience Qualifications

• Minimum of five (5) years experience in healthcare setting.
• Chronic care/case management experience

Skills and Abilities

• Understanding of chronic disease processes, preventive care guidelines, care coordination principles, and social determinants of health influencing patient outcomes.
• Ability to stratify patient populations, identify care gaps, and apply risk adjustment principles to support accurate coding and effective management of high‑risk patients.
• Strong verbal and written communication skills, including active listening, motivational interviewing, and the ability to explain treatment regimens in an accessible manner.
• Skill in coordinating transitions of care, navigating community and ancillary resources, and resolving barriers to care for complex or high‑risk patients.
• Experience using electronic health records (e.g., Epic, Cerner) and comfort working in remote environments with the ability to maintain professional standards and productivity expectations.
• Ability to function independently, manage multiple priorities, maintain documentation accuracy, and keep team members and leadership informed of patient or workflow needs.

Primary Location

Tampa

Work Locations

USF Faculty Office Building 13220 USF Laurel Dr Tampa 33612

Eligible for Remote Work : Hybrid Remote

Job

Case Management

Organization

Academic Medical Group Inc

Schedule

Full-time

Scheduled Days : Monday, Tuesday, Wednesday, Thursday, Friday