Job Title: Value-Based Care RN

Req: 2025-1402

Location:

Department: Ambulatory Education and Training

Shift: Days

Type: Full Time

FTE: 1

Hours: Monday – Friday or as assigned.

City State: Renton, WA

Category Professional

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

Job Description:

JOB DESCRIPTION

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.

This salary range may be inclusive of several career levels at Valley Medical Center and will be narrowed during the interview process based on several factors, including (but not limited to) the candidate's experience, qualifications, location, and internal equity.

TITLE: Value-Based Care RN

JOB OVERVIEW: The Value-Based Care Registered Nurse (VBC RN) plays a vital role in supporting patient-centered, outcomes-driven healthcare delivery. The RN will work collaboratively with interdisciplinary teams to coordinate care for patients, reduce unnecessary utilization, improve chronic disease outcomes, and optimize performance under value-based care contracts (e.g., ACOs, Medicare Advantage, commercial risk). The VBC RN supports care coordination, patient education, transitional care, and proactive outreach to manage high-risk and rising-risk populations. Remote work is available. May be required to travel to different clinic sites.

DEPARTMENT: Clinic Network

WORK HOURS: Monday- Friday; Hours may vary to meet departmental and patient needs.

REPORTS TO: Manager, Care Management

Prerequisites:

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).

Case Management or Care Coordination Certification preferred.

Qualifications:

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.

Unique Physical/Mental Demands, Environment And Working Conditions:

Requires sitting for extended periods of time.

May require standing and walking for extended periods of time.

Requires ability to lift and carry items weighing up to 50 pounds.

Requires correct vision and hearing to normal range.

Requires ability to communicate effectively both verbally and in writing.

Requires working under changing conditions.

May have exposure to communicable diseases or body fluids and other conditions common to the clinical environment.

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.

Monitor 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.

Created: 8/2025

Revised:

Grade: NC-11

FLSA: E

Cost Center: 8317

Qualifications:

Job Qualifications:

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.