Value-Based Care RN: Transitions of Care & Care Management

Cone Health; Greensboro (NC); On-site; USD 75,000 - 105,000; Full time

Job summary

Cone Health is seeking an RN Care Manager for our VBCI Population Health program. You will assess, plan, coordinate, and evaluate care for a diverse patient population, focusing on high-quality, patient-centered services.

You will collaborate with interdisciplinary teams, educate patients, and leverage data to improve outcomes and reduce readmissions. The role emphasizes care coordination and advocacy within Cone Health system and THN ACO populations.

Qualifications

• Two years minimum as outpatient RN Care Manager managing adults with complex needs.
• Alternate: five years as RN in acute/home care managing adults.
• CCM certification preferred.

Responsibilities

• Collaborate with interdisciplinary teams to develop and manage care plans.
• Act as liaison to ensure continuity of care across settings.
• Educate patients and families about conditions, options, and self-management.
• Use motivational interviewing and teach-back techniques.
• Assess and monitor to optimize outcomes and reduce readmissions.
• Review and adjust care plans based on progress and data.
• Support care gap closure and coordinate community resources.
• Document in EHR and participate in quality improvement initiatives.
• Advocate for patient preferences in planning and decisions.

Skills

Case management

Care coordination

Patient engagement

Motivational interviewing

Teach back

Assessment

Data management

Quality improvement

Care gaps

Advocacy

Reporting & analytics

Clinical expertise

Education

Graduate from Specialty Training Program - Nursing

BSN preferred

Tools

EHR systems

Job description

Cone Health is seeking an RN Care Manager for our VBCI Population Health program. You will assess, plan, coordinate, and evaluate care for a diverse patient population, focusing on high-quality, patient-centered services.

You will collaborate with interdisciplinary teams, educate patients, and leverage data to improve outcomes and reduce readmissions. The role emphasizes care coordination and advocacy within Cone Health system and THN ACO populations.