Position Summary:

We are seeking a highly motivated and results-driven Nurse Practitioner (NP)/ Registered Nurse (RN) to support Primary Care Physicians (PCPs) and practice teams in managing quality measures, closing care gaps (HEDIS/STARS), and overseeing care management for high-cost, high-risk patients. This role will be critical in ensuring that our practices achieve and outperform all HEDIS/STARS quality requirements set by CMS and Medicare Advantage (MA) health plans.

The NP/ RN will work closely with the Operational Excellence Team, PCPs, practice managers, care coordinators, and health plan representatives to implement best practices for quality improvement, patient engagement, risk reduction, and care management strategies.

This is a strategic, field-based role requiring both clinical expertise and data-driven problem- solving skills to drive measurable improvements in patient care outcomes across our Medicare Advantage Full Risk Value-Based Care (VBC) network.

Key Responsibilities:

• HEDIS, STARS, and Quality Measures Performance Improvement

• Act as the clinical quality lead for assigned PCPs and practices, guiding them to achieve and exceed HEDIS and STARS benchmarks.
• Collaborate with PCPs and care teams to close care gaps by ensuring timely preventive screenings, vaccinations, chronic disease management, and follow-ups.
• Conduct gap analysis to identify barriers to HEDIS compliance and create action plans to improve STARS ratings and overall performance.
• Provide real-time coaching to providers and staff on best practices for capturing accurate data, improving documentation, and adhering to quality measures.
• Monitor CMS and health plan quality reporting dashboards to track performance trends, areas of improvement, and gaps in care.
• Partner with EHR/technology teams to optimize workflows for seamless data capture and reporting of HEDIS measures.

• Case Management & High-Risk Patient Engagement

• Develop and execute targeted care plans for high-cost, high-risk Medicare Advantage patients to reduce hospitalizations, ER visits, and readmissions.
• Work closely with care coordinators, case managers, and social workers to ensure high-risk patients receive timely interventions, specialist referrals, and follow-up care.
• Identify barriers to care adherence (e.g., social determinants of health, transportation, medication access) and implement solutions to improve patient outcomes.
• Collaborate with payors and population health teams to stratify patients by risk level and ensure proactive outreach to prevent disease progression.
• Lead transitional care management (TCM) initiatives to support patients post-hospital discharge and ensure adherence to post-discharge care plans.

• Provider & Practice Support for Operational Excellence

• Serve as a clinical trainer to PCPs, practice managers, and medical staff on best practices for quality improvement and patient engagement.
• Conduct workflow assessments in PCP offices to streamline processes for optimal quality measure reporting and patient outreach.
• Train PCPs and staff on documentation best practices to maximize accuracy and care gap closure.
• Work with the health IT and analytics team to ensure PCPs have real-time access to actionable data for improving HEDIS/STARS performance.

• Health Plan & CMS Compliance Alignment

• Ensure that all clinical interventions, care management activities, and documentation align with CMS requirements and health plan contracts.
• Work closely with payor partners to stay updated on quality incentives, performance metrics, and reimbursement opportunities related to HEDIS/STARS.
• Participate in quality-focused initiatives and serve as a liaison between PCPs, MSO leadership, and health plans to drive alignment on quality goals.

Key Performance Goals (KPIs):

• Achieving & exceeding HEDIS/STARS benchmarks for all assigned PCP practices.
• Increasing care gap closure rates (preventive screenings, chronic condition management, immunizations).
• Reducing avoidable hospitalizations, ER utilization, and readmissions among high-risk patients.
• Enhancing provider engagement & adoption of best practices for quality documentation and workflow improvements.
• Improving patient adherence & engagement through targeted care management strategies.

Key Performance Goals (KPIs):

• Achieving & exceeding HEDIS/STARS benchmarks for all assigned PCP practices.
• Increasing care gap closure rates (preventive screenings, chronic condition management, immunizations).
• Reducing avoidable hospitalizations, ER utilization, and readmissions among high-risk patients.
• Enhancing provider engagement & adoption of best practices for quality documentation and workflow improvements.
• Improving patient adherence & engagement through targeted care management strategies.

Qualifications & Requirements Education & Experience:

• Licensed Nurse Practitioner (NP) or Licensed Registered Nurse (RN)
• Minimum 3 years of clinical experience in primary care, population health, or care management.
• Experience working in Medicare Advantage, HEDIS/STARS, or value-based care models (preferred).
• Knowledge of CMS quality measures, risk adjustment (HCC coding), and care coordination (preferred).

Skills & Competencies:

• Deep understanding of HEDIS, STARS, and CMS quality improvement programs.
• Ability to analyze data, identify care gaps, and implement evidence-based interventions.
• Excellent communication and training skills to educate providers and staff on quality improvement strategies.
• Proficiency in Electronic Health Records (EHR) and data analytics tools to track performance trends.
• Strong collaboration skills to work with PCPs, MSO leadership, care teams, and payor representatives.
• Commitment to health equity, patient-centered care, and optimizing clinical outcomes.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!