RN Care Manager, Population Health Programs

RN Care Manager, Population Health Programs at DuetAbout Duet : Duet is on a mission to transform primary care by empowering nurse practitioners (NPs) to own and operate their practices. By providing NPs with tailored products and services within a supportive setting, Duet is building the nation’s largest network of NP-owned practices, driving better outcomes for patients and communities.Role OverviewThe Registered Nurse Care Manager (RNCM) will be the founding clinical hire for our Medicare care management programs. This is an opportunity to help design, operationalize, and scale a best-in-class value-based care management model from the ground up.The RNCM will deliver longitudinal, relationship-based care to Medicare beneficiaries while also partnering closely with leadership to build workflows, define best practices, and shape the future of the program. This role blends hands-on clinical care management with operational leadership and program development.This position is ideal for an RN who is entrepreneurial, systems-oriented, and excited to build a care management playbook.Key ResponsibilitiesClinical Care ManagementConduct comprehensive assessments for Medicare beneficiaries, including medical, behavioral, and social needsDevelop and manage individualized care plans aligned with evidence-based guidelinesProvide chronic condition management (e.g., diabetes, CHF, COPD, hypertension)Perform medication reconciliation and adherence supportDeliver patient education, coaching, and self-management supportCare Coordination & TransitionsCoordinate care across primary care, specialists, hospitals, post-acute, and community resourcesManage transitions of care following ED visits or hospitalizationsClose care gaps related to preventive care, screenings, and quality measuresProgram Building & Operational LeadershipDesign and refine care management workflows from enrollment through ongoing engagementBuild documentation standards to support APCM and other care management billing programsPartner with analytics and operations to define caseload models, outreach triggers, and performance metricsIdentify gaps in process and implement scalable solutionsHelp select and optimize care management tools and EHR workflowsContribute to hiring plans, onboarding materials, and training content as the team growsServe as a clinical thought partner to leadership on ACO and value-based strategyValue-Based Program SupportSupport 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 admissionsPartner with operations and analytics teams to track outcomes and performanceCollaboration & CommunicationServe as a core member of the interdisciplinary care teamCommunicate regularly with patients, caregivers, and providers via phone and video settingsEscalate clinical concerns appropriately and support clinical decision-makingQualificationsActive 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 preferredDemonstrated ability to build or improve clinical workflowsStrong operational mindset with comfort in ambiguity and early-stage environmentsFamiliarity with value-based care models (ACO, MSSP, APCM, CCM)Strong care coordination, documentation, and patient engagement skillsComfortable working in a hybrid NYC-based role with in-person collaborationKnowledge of social determinants of health and community-based resourcesWho Will Thrive HereBuilder-minded RN leaders who are excited to design workflows — not just follow themClinicians who think in systems, seeing both the individual patient journey and the operational engine behind itThoughtful relationship-builders who get energy from helping others succeedHigh EQ, low ego, and a bias toward actionSelf-starters who love learning, growing, and wearing multiple hatsPeople who bring joy, humility, and hustle to their workThis role is hybrid, based in NYC.Salary range: $85K-$110K