RN Care Manager, Population Health Programs

Responsibilities

• Conduct comprehensive assessments for Medicare beneficiaries including medical, behavioral, and social needs
• Develop and manage individualized care plans aligned with evidence-based guidelines
• Provide chronic condition management for diabetes, CHF, COPD, and hypertension
• Coordinate care across primary care, specialists, hospitals, and community resources
• Design and refine care management workflows and documentation standards
• Partner with analytics and operations to define caseload models and performance metrics
• Support ACO quality and utilization goals such as HEDIS and STARs
• Manage transitions of care following ED visits or hospitalizations

Requirements

• Active RN license in New York State
• 3+ years of clinical nursing experience
• Experience with Medicare populations strongly preferred
• Familiarity with value-based care models (ACO, MSSP, APCM, CCM)
• Demonstrated ability to build or improve clinical workflows
• Strong operational mindset and comfort with ambiguity
• Knowledge of social determinants of health

About the Company

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.