Manager - Clinical Care Coordination

The Manager - Clinical Care Coordination - Continuum of Care is responsible for the leadership, oversight, development, implementation, and ongoing management of the Continuum of Care program. The Manager provides direct supervision of Clinical Care Coordinators and serves as a clinical and operational leader supporting care coordination activities across the continuum including ambulatory settings, freestanding emergency departments, post-acute providers, community resources, and transitions of care. The Manager collaborates with physicians, advanced practice providers, operational leaders, population health teams, case management, social workers, quality, and community partners to improve care transitions, reduce avoidable utilization, enhance patient engagement, improve quality outcomes, and support organizational population health initiatives. The position functions as a working manager and may directly assist with high-risk patient care coordination activities, staff coverage, program development, and special projects. The Manager is accountable for program performance, staff development, quality outcomes, productivity monitoring, regulatory compliance, patient satisfaction, readmission reduction, emergency department utilization reduction, and achievement of organizational strategic goals.

• Collaborates with patients, families, physicians, advanced practice providers, free standing emergency department staff, ambulatory practices, post-acute providers, and community resources to coordinate care across the continuum and facilitate safe, efficient transitions between care settings and timely follow-up.
• Identifies patients at increased risk for hospitalization, readmission, emergency department utilization, poor health outcomes, or unmet social needs; develops and implements individualized care plans to address clinical, psychosocial, and resource needs.
• Assesses barriers to care, including social determinants of health, and connects patients with internal and external resources to support treatment adherence, self-management, access to care, and overall well-being.
• Serves as a clinical and operational resource for staff, providers, and leadership regarding care coordination, population health management, social determinants of health, and community resource utilization.
• Partners with organizational leaders to support strategic initiatives, value-based care objectives, population health programs, and departmental budget and resource planning.
• Ensures compliance with applicable regulatory, accreditation, payer, and organizational requirements governing care coordination and patient management activities.
• Performs direct care coordination or program support activities as needed to maintain operational effectiveness and ensure uninterrupted patient services.
• Maintains responsibility for department’s operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards.
• Manages team members which includes orientation, development and evaluation of personnel, and monitoring the provision of delivering quality services. Participates in the recruiting, interviewing and selecting of team members following policies, guidelines and applicable laws. Evaluates their performance relative to job goals and requirements. Provides coaching to staff, recommends in-service education programs, and ensures adherence to internal policies and standards.
• Maintains responsibility for the fiscal management of department and assures proper utilization of organization’s financial resources.
• Effectively communicates departmental, organization, and industry information to staff.

Minimum Education

• Technical Diploma/Certificate Nursing Required or
• Associates Degree Nursing Required

Minimum Work Experience

• 3 years Clinical nursing experience. Required
• 2 years Case management, care coordination, population health, utilization management, discharge planning, or transitional care management experience. Preferred
• 2 years Leadership, supervisory, charge nurse, project leadership, program coordination, or management experience. Preferred
• 3 years Experience working with high-risk populations, chronic disease management, readmission prevention, or community-based care coordination programs. Preferred

Licenses and Certifications

• Registered Nurse Licensed State of Florida or eligible compact state Upon Hire Required

Required Skills, Knowledge and Abilities

• Demonstrated leadership and team-building skills.
• Strong knowledge of care coordination, transitional care management, population health, and community resource management.
• Knowledge of reimbursement methodologies and quality performance measures.
• Ability to analyze data and utilize metrics to drive operational improvement.
• Strong critical thinking and clinical decision-making skills.
• Effective communication, presentation, and relationship-building skills.
• Ability to lead multidisciplinary teams and influence positive change.
• Knowledge of social determinants of health and community-based care resources.
• Strong organizational, project management, and problem-solving abilities.
• Ability to manage multiple priorities in a dynamic healthcare environment.
• Proficiency with electronic medical records and data reporting systems.