Care Manager - USFTGP UMSA Quality and Safety

Education Qualifications

• Associate’s Degree Nursing

Licenses and Certifications

• Registered Nurse
• Ambulatory Care Nursing
• Telehealth Nursing Certification
• Case Management Certification
• Certified Professional in Healthcare Quality

Experience Qualifications

• Minimum of five (5) years experience in healthcare setting.
• Chronic care/case management experience

Skills and Abilities

• Understanding of chronic disease processes, preventive care guidelines, care coordination principles, and social determinants of health influencing patient outcomes.
• Ability to stratify patient populations, identify care gaps, and apply risk adjustment principles to support accurate coding and effective management of high‑risk patients.
• Strong verbal and written communication skills, including active listening, motivational interviewing, and the ability to explain treatment regimens in an accessible manner.
• Skill in coordinating transitions of care, navigating community and ancillary resources, and resolving barriers to care for complex or high‑risk patients.
• Experience using electronic health records (e.g., Epic, Cerner) and comfort working in remote environments with the ability to maintain professional standards and productivity expectations.
• Ability to function independently, manage multiple priorities, maintain documentation accuracy, and keep team members and leadership informed of patient or workflow needs.

The Care Manager supports high‑risk patients across the continuum of care by serving as a primary point of contact for patients and their multidisciplinary care teams. This role focuses on improving outcomes for patients in the ambulatory setting by identifying gaps in preventive and chronic disease management, reducing avoidable acute care utilization, and implementing individualized care plans. Working closely with USFTGP's physician offices, the Care Manager optimizes quality performance, risk adjustment processes, and overall population health management. The position may include conducting health coaching, chronic care management, Annual Wellness Visits, behavioral interviewing, and care transitions while collaborating with Accountable Care Organization (ACO) and value based care initiatives, managed care partners, and community resources. The Care Manager functions autonomously, maintains strong communication and organizational skills, and provides an exceptional patient experience while working both remotely and on-site as needed.

Essential Functions 

• Assess high‑risk patients by performing Annual Wellness Visits (AWVs), chronic care management evaluations, and needs assessments to identify care gaps and risk factors.
• Provide clinical health coaching to support patient self‑management of chronic conditions, lifestyle changes, and adherence to treatment plans.
• Evaluate social determinants of health and connect patients to community resources to reduce health risks and improve outcomes.
• Implement individualized, multidisciplinary plans of care to prevent avoidable emergency department visits, hospitalizations, and disease progression.
• Coordinate transitions of care, ensuring timely referrals, follow‑up appointments, and communication with ancillary providers and community agencies.
• Collaborate with primary care offices, ACO partners, and managed care staff to align with value‑based payment models and organizational population health goals.
• Utilize risk adjustment principles to stratify patient panels and manage high‑risk populations effectively and efficiently.
• Maintain thorough and timely documentation in the electronic health record and meet all productivity and performance expectations.
• Use behavioral interviewing and active listening techniques to understand patient concerns, reduce resistance, and support positive health behaviors.
• Work autonomously within remote and in‑person settings, maintaining strong communication with the provider care team, leadership, and partners across the continuum of care.