CLINICAL MANAGER - INTEGRATED CARE

About the role

At Matter of Care, we believe the most important moments in healthcare happen after a patient leaves the hospital. As a Clinical Manager – Integrated Care, you'll play a vital leadership role in ensuring participants receive seamless, high-quality care as they transition safely home. This role partners with physicians, hospital discharge teams, home care clinicians, and interdisciplinary teams to reduce readmissions and improve outcomes. Matter of Care is a member of the CenterLight Health System family and is dedicated to helping older adults receive high-quality, coordinated healthcare services while maintaining their independence and dignity. Through a participant-centered approach and strong community partnerships, we work every day to improve health outcomes and quality of life for the individuals and families we serve.

Responsibilities

• Lead hospital-to-home care transitions and develop individualized transition plans.
• Collaborate with hospital discharge planners, physicians, and interdisciplinary teams.
• Conduct comprehensive in-home nursing assessments and provide skilled nursing care.
• Educate participants and caregivers on medications, chronic disease management, and follow-up care.
• Serve as an active member of the Interdisciplinary Team (IDT).
• Supervise and mentor Nurses, Personal Care Aides, and Home Health Aides.
• Conduct supervisory field visits and competency assessments.
• Ensure compliance with PACE, LHCSA, CMS, and organizational standards.
• Participate in quality improvement initiatives and maintain accurate documentation.

Requirements

• Active, unrestricted New York State RN license.
• Graduate of an accredited nursing program (BSN preferred).
• Minimum 3 years of clinical nursing experience.
• 1–2 years in home care, community health, or similar setting.

Qualifications

• PACE experience.
• Care Transitions experience.