Serve as PPWPA account executive for CIN recruitment, questions and escalation of issues and PPWPA alignment. Coordinates regional POD activities and general support. Central Point of contract for escalation of issues.

Assists with practice onboarding; Performs practice capability assessments and collaboratively develops practices plans. Helps practices to implement CIN initiatives; provides training to staff and providers to utilize and understand cost reports and analytics technology.  Provides training and fosters adoption of optimized workflows, enhanced panel management techniques, improved EHR technology utilization, and education on regional quality cost and utilization opportunities, all designed to improve patient access to high value care, prevent unnecessary episodes of high cost care and improve patient outcomes.  Facilitates introduction/implementation of Primary Care transformation initiatives, PCMH principles and Cath Pathways.

Serves as a quality steward for quality metric management. Works directly with the PCP teams to ensure high quality care is reflected in data submissions to CIN payers. Addresses quality gap issues that impact the health of the patient, and review clinical EHR documentation to verify preventive services have been provided according to evidence based schedules. Works with CIN Patient Registries and practice Electronic Health Record or paper record to support reporting and monitoring of quality metric performance.  

The High Risk Care Managers work in concert with the patient's primary care team and CIN experts to provide direct telephone and/or visit based care management services addressing comprehensive challenges that impact the health of the patient, while reducing unnecessary healthcare utilization. Working with the most vulnerable patients, these nurses collaborate with the health care team to establish a comprehensive goal-driven care plan, that addresses the patient's chronic disease, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers.