Registered Nurse Care Manager -Value Care; Reside in FL

Cardiovascular Services Of America (Cvausa)

Cardiovascular Services of America (CVAUSA) is the largest private and independent cardiology network in the United States. Our inclusive and diverse network brings together top cardiovascular specialists and thought leaders who offer regional perspectives and a broad strategic vision for the future of patient care. Headquartered in Orlando area, Cardiovascular Associates of America aims to bring the best cardiovascular physicians in one network with the common mission of saving lives, reducing costs, and improving patient care through clinical innovation.

Novocardia, a division of CVAUSA, is on a mission to revolutionize cardiovascular care and empower clinicians across the United States to consistently deliver high-quality, prevention-focused, value-based, patient centered care.

The RN Care Manager provides clinical oversight and care management for a dedicated POD model staffed with Medical Assistants and Health Coaches, supporting cardiac patients under value-based agreements. This role is responsible for driving high-quality, cost-effective care through proactive clinical oversight, multidisciplinary collaboration, risk stratification, and care transitions. The RN Care Manager serves as the clinical leader for the POD, ensuring care plans align with NCQA documentation requirements, contractual quality measures, and organizational performance goals.

This role plays a critical part in risk mitigation, utilization management, and patient engagement across the continuum of care.

• 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.

• 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

• Clinical judgment and critical thinking
• Leadership and team facilitation
• Patient-centered communication
• Data-driven decision- making
• Adaptability in a fast-paced, outcomes-focused environment
• Commitment to high-quality, value-based care delivery

• Remote position requiring a dedicated, private workspace and reliable high-speed internet to ensure patient privacy and compliance with HIPAA standards.

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

Novocardia provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to…