Skills1.Strong patient communication, engagement, education, and motivational support.2.Ability to assess patient needs, interpret clinical and population health data, identify care gaps, and support appropriate interventions.3.Ability to effectively coordinate care and collaborate with providers and interdisciplinary teams.4.Strong organizational, time management, documentation, and follow-up skills.5.Ability to effectively utilize EHR, population health, payer, and other technology and reporting tools to support patient care and program goals. General Summary: The Value-Based Care Nurse Care Manager primarily supports Medicare patients and organizational goals by proactively identifying high-risk patients, closing care gaps, coordinating care, improving preventive and chronic disease management, and reducing avoidable healthcare utilization.