Population Health & Care Management Nurse

About Us

Advanced Care Specialists (ACS) is a growing, multidisciplinary healthcare organization committed to delivering high-quality, patient-centered care across primary care and specialty services. As we expand our value-based care initiatives, we are seeking a clinically experienced nurse to lead our Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), and Transitional Care Management (TCM) programs.

This is not a traditional bedside role. This is a systems-driven, population health leadership position focused on compliance, care coordination, and measurable outcomes.

Position Summary

The Population Health & Care Management Nurse will oversee the daily operations, documentation, compliance, and performance of Medicare care management programs. The ideal candidate has direct experience running CCM and/or RPM programs in a primary care setting and understands CMS time-based billing requirements.

This role plays a critical part in improving patient engagement, reducing readmissions, supporting HCC/RAF capture, and ensuring audit-ready documentation.

Key Responsibilities:

Chronic Care Management (CCM)

• Identify and enroll eligible patients (2+ chronic conditions)
• Obtain and document patient consent
• Develop and maintain comprehensive electronic care plans
• Ensure monthly time thresholds are met and properly documented
• Coordinate care across providers and specialists

Remote Patient Monitoring (RPM)

• Enroll patients and oversee device onboarding
• Monitor biometric data and respond to alerts
• Perform clinical outreach for abnormal readings
• Maintain compliance with CMS documentation requirements

Remote Therapeutic Monitoring (RTM)

• Track therapeutic adherence and response for musculoskeletal patients
• Coordinate with rehab and orthopedic providers
• Ensure proper documentation for billing compliance

Transitional Care Management (TCM)

• Complete 48-hour post-discharge outreach
• Perform medication reconciliation
• Coordinate follow-up care within required timeframes
• Document services to support CPT 99495/99496 billing

Population Health & Quality

• Assist in identifying care gaps and supporting RAF/HCC capture
• Track program performance metrics
• Collaborate with billing and leadership to ensure compliance
• Participate in workflow improvement and program growth

Qualifications

Required

• Active RN license (preferred) or experienced LPN with direct CCM/RPM program management experience
• 2+ years in a primary care setting
• Direct experience with CCM and/or RPM programs
• Strong understanding of CMS time-based billing requirements
• Proficiency in EHR documentation (eClinicalWorks experience preferred)

Preferred

• Experience with Medicare Advantage or value-based care models
• Familiarity with HCC/RAF documentation
• Experience scaling or launching care management programs

What We’re Looking For

• Highly organized and detail-oriented
• Strong clinical judgment and triage skills
• Comfortable working independently
• Systems-minded with strong documentation integrity
• Collaborative and proactive communicator

Compensation & Benefits

• Competitive salary (based on experience)
• Health benefits
• PTO
• 401(k)
• Opportunity to help build and shape a growing value-based care program

Why Join ACS?

This role directly impacts patient outcomes and the future growth of our primary care model. If you are experienced in care management programs and want to move beyond task-based nursing into population health leadership, this is a unique opportunity to build and lead.

Job Type: Full-time

Pay: $35.00 - $40.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Health insurance
• Paid time off

Work Location: In person