Value-Based Care RN (2026-0642)

Job Overview

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

About the Role

The position is located in the Ambulatory Education and Training Department within the Clinic Network. Work hours are Monday- Friday; hours may vary to meet departmental and patient needs. Reports to the Manager, Care Management.

Qualifications

• Graduation from an accredited school of nursing approved by the Washinton State Board of Nursing.
• BSN preferred.
• Current Washington Registered Nurse (RN) License required.
• AHA BLS for healthcare providers required.
• Minimum 3 Years' Experience As a Registered Nurse, Required.
• PREFERRED: Hospital-based environment experience in specialty area.
• Experience working with population with chronic conditions (e.g., Diabetes, CHF, COPD).
• Care Management or Care Coordination Certification preferred.

Skills

Applies knowledge of scope and role of the Registered Nurse. Demonstrates independent critical thinking skills with the ability to assess situations, problem solve and effectively make decisions. Establishes and maintains effective working relationships with other health care team members, patients, families, and outside care providers. Able to communicate and work effectively with the physical and emotional development of all age groups. Utilizes interpersonal communication strategies to achieve desired outcomes with patients and families. Demonstrates awareness and sensitivity to patient and family rights as identified within the institution. Functions with an awareness of safety needs and assures adherence with organization and regulatory environmental safety standards. Demonstrates understanding of and commitment to sound financial management and viability of the organization. Demonstrates flexibility and manageability of multiple demands. Demonstrates self-responsibility, accountability for practice and professional development. Knowledge of social determinants of health and their impact on patient outcomes.

Benefits

Remote work is available. May be required to travel to different clinic sites.

Pay

Min $94,894 - Max $142,341/annual DOE

Schedule

Days

Performance Responsibilities

Generic Job Functions: See Generic Job Description for Clinical Partner Essential Responsibilities And Competencies:

• Identifies patient populations requiring care management support.
• Coordinate and manage care for patients with chronic conditions, complex care needs, or recent hospitalizations.
• Perform comprehensive assessments (clinical, functional, psychosocial) to identify gaps in care and barriers to health.
• Develop strategies to meet preventive care and health maintenance measures for populations of patients.
• Serve as an advocate for the patient.
• Assess access and engage patient in resources that require clinical licensing, training, or knowledge.
• Provide telephonic and/or in-person outreach to patients for coaching, education, and care planning.
• Collaborate with physicians, social workers, pharmacists, and care coordinators to ensure integrated care delivery.
• Utilize electronic health records (EHR) and care management platforms to document interventions and track patient progress.
• Support transitions of care by ensuring appropriate follow-up post-hospital discharge or emergency department visits.
• Monitor patients' adherence to care plans, including medication management and appointment compliance.
• Participate in quality improvement initiatives aligned with value-based metrics such as HEDIS, STAR ratings, and patient satisfaction.
• Use data analytics to identify trends, prioritize interventions, and improve patient outcomes, including overseeing ED and hospital admission utilization rates.
• Educate patients and families on disease management, preventive care, and healthy lifestyle choices.
• Maintain compliance with HIPAA, clinical protocols, and all regulatory requirements.
• Acts as a liaison between clinics, other hospital departments and community resources.
• Provide appropriate education and instructions to patients and family regarding treatment plans.
• Provide initial patient education and follow-up reinforcement at scheduled patient appointments.
• Maintain device/s and consult licensed providers as indicated to support optimal patient care.
• Coordinate patient referrals, appointments, testing and admissions to other facilities.
• Manage patient populations requiring care management support by assessing healthcare and psychosocial needs, identifying resources needed, ongoing educational needs, management of chronic condition and access to community resources, as well as a partnership with the primary provider of care.
• Utilizes decision support tools for symptom based and emergent care.
• Assure timeliness and quality of documentation and billing compliance.
• Performs other duties as assigned.