Organization Overview, Mission, Vision, and Values
Our mission is to improve the health of people in the communities we serve through compassionate, high-quality care, prevention, and wellness education. Washington Regional Medical System is a community-owned, locally governed, non-profit health care system located in Northwest Arkansas in the heart of Fayetteville, which is consistently ranked among the Best Places to live in the country. Our 425-bed medical center has been named the #1 hospital in Arkansas for five consecutive years by U.S. News & World Report. We employ 3,200+ team members and serve the region with over 40 clinic locations, the region’s only Level II trauma center, and five Centers of Excellence - the Washington Regional J.B. Hunt Transport Services Neuroscience Institute; Washington Regional Walker Heart Institute; Washington Regional Women and Infants Center; Washington Regional Total Joint Center; and Washington Regional Pat Walker Center for Seniors.
Position Summary
The Care Manager (CM) supports patients across the care continuum by performing nurse-led Medicare Annual Wellness Visits (AWVs), providing case management and complex care management, and driving enrollment in Advanced Primary Care Management (APCM). This role works closely with providers and clinical operations to close care gaps, improve quality outcomes, and support patients with chronic and complex needs in a value-based care environment. The CM operates within Epic and other care management platforms to document, track, and coordinate patient care activities.
Essential Position Responsibilities
Nurse-Led Medicare Annual Wellness Visits (AWV)
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Independently perform nurse-led AWVs under applicable state scope of practice and CMS direct supervision requirements
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Conduct the full AWV visit, including Health Risk Assessments (HRAs), cognitive screenings, functional/safety screenings, and development of a personalized prevention plan
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Review and reconcile medication lists, screening histories, and immunization status with the patient
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Document the visit to meet CMS requirements for AWV billing (G0438/G0439)
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Identify and close associated quality measure gaps during the visit, per established protocols
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Escalate any clinical concerns to the supervising provider for review and sign-off
Case Management
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Conduct patient assessments to identify medical, behavioral, and social needs
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Coordinate referrals to community resources.
APCM Enrollment
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Identify patients eligible for Advanced Primary Care Management based on CMS risk stratification criteria
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Educate patients and caregivers on APCM program benefits and obtain consent for enrollment
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Coordinate with billing/compliance staff to ensure documentation supports appropriate service level.
Complex Care Management
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Manage a caseload of patients with multiple chronic conditions, high utilization, or elevated risk scores
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Develop and maintain individualized care plans in collaboration with the care team
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Perform regular outreach (telephonic, MyChart, in-person) to monitor status and reinforce care plans
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Provide patient and caregiver education on diagnoses, treatment plans, and self-management
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Collaborate with interdisciplinary team members on complex cases
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Escalate urgent clinical concerns per established protocols
Documentation & Quality
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Maintain accurate, timely documentation in Epic consistent with organizational and regulatory standards
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Support HEDIS and other quality measure compliance through accurate coding and gap closure documentation
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Participate in quality improvement initiatives and case reviews
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Track and report on productivity and outcome metrics as defined by leadership
Qualifications
Required
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Current, unencumbered RN license in the state of Arkansas
- Minimum 2 years of clinical experience in primary care, case management, or care coordination
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Strong understanding of Medicare AWV, CCM, and/or APCM program requirements
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Proficiency with EHR systems (Epic preferred)
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Excellent communication, organization, and interpersonal skills
Preferred
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Experience in a value-based care or ACO environment
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Familiarity with HEDIS quality measures
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Case Management certification (CCM) or willingness to obtain within a defined timeframe
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Experience with population health/risk stratification tools
Core Competencies
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Patient-centered communication and motivational interviewing
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Time management across a mixed caseload (scheduled visits, telephonic outreach, documentation)
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Critical thinking and clinical judgment for escalation decisions
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Collaborative, team-based approach to care delivery
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Comfort with data tracking and quality metric reporting
Work Environment: This role requires a combination of clinical and office-based activity. The position may involve extended periods of standing and walking, as well as occasional pushing, pulling, lifting, or carrying materials up to 50 pounds. The role also includes time spent sitting and working in a standard office environment. Depending on the care setting, the position may be exposed to communicable diseases, bodily fluids, and other typical healthcare workplace conditions. This position serves a culturally and linguistically diverse patient population.
Notice: This job description is designed to provide an overview of the essential and principal duties and responsibilities of the position. The job description is not designed or intended to cover or set forth a comprehensive listing of all activities, duties or responsibilities that are required of the employee. Washington Regional reserves the right in its absolute discretion to change duties, responsibilities or activities or assign new duties, responsibilities, or activities at any time with or without notice. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
