RN Care Manager, Population Health Programs

RN Care Manager, Population Health Programs at Duet About 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 Overview The 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 Responsibilities Clinical Care Management 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 (e.g., diabetes, CHF, COPD, hypertension) Perform medication reconciliation and adherence support Deliver patient education, coaching, and self-management support Care Coordination & Transitions Coordinate care across primary care, specialists, hospitals, post-acute, and community resources Manage transitions of care following ED visits or hospitalizations Close care gaps related to preventive care, screenings, and quality measures Program Building & Operational Leadership Design and refine care management workflows from enrollment through ongoing engagement Build documentation standards to support APCM and other care management billing programs Partner with analytics and operations to define caseload models, outreach triggers, and performance metrics Identify gaps in process and implement scalable solutions Help select and optimize care management tools and EHR workflows Contribute to hiring plans, onboarding materials, and training content as the team grows Serve as a clinical thought partner to leadership on ACO and value-based strategy Value-Based Program Support Support 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 admissions Partner with operations and analytics teams to track outcomes and performance Collaboration & Communication Serve as a core member of the interdisciplinary care team Communicate regularly with patients, caregivers, and providers via phone and video settings Escalate clinical concerns appropriately and support clinical decision-making Qualifications Active 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 preferred Demonstrated ability to build or improve clinical workflows Strong operational mindset with comfort in ambiguity and early-stage environments Familiarity with value-based care models (ACO, MSSP, APCM, CCM) Strong care coordination, documentation, and patient engagement skills Comfortable working in a hybrid NYC-based role with in-person collaboration Knowledge of social determinants of health and community-based resources Who will thrive here: Builder-minded RN leaders who are excited to design workflows — not just follow them Clinicians who think in systems, seeing both the individual patient journey and the operational engine behind it Thoughtful relationship-builders who get energy from helping others succeed High EQ, low ego, and a bias toward action Self-starters who love learning, growing, and wearing multiple hats People who bring joy, humility, and hustle to their work This role is hybrid, based in NYC. Salary range: $85K-$110K