Leader, Clinical Support & Care Services (RN Required)

Responsibilities

• Care Coordination & Care Planning (30%): Lead the team responsible for comprehensive care plan creation, updating, and documentation. Oversee identification and closure of care gaps across conditions, screenings, and preventive care. Coordinate interdisciplinary care teams (clinical, behavioral, social work, community resources). Manage high-risk patient workflows: follow-up, monitoring, and escalation.
• Advance Care Planning & Goals of Care (15%): Oversee facilitation of serious illness conversations and advance care planning discussions. Guide team in developing POLST forms, advance directives, and palliative support pathways. Ensure appropriate documentation and communication of patient preferences.
• DME, Home Health & LTSS Coordination (20%): Lead all DME ordering, tracking, and vendor coordination. Oversee Home Health referrals, follow-up, and completion confirmation. Manage LTSS navigation, including personal care services, home modifications, and waiver programs. Ensure efficient workflows for resource requests from field clinicians.
• Social Determinants of Health & Community Resources (10%): Lead SDOH screening, assessment, and intervention protocols. Manage community resource referral pathways (food, transportation, housing, caregiver support). Develop and maintain partnerships with community organizations and local resource providers.
• Care Transitions Management (10%): Oversee hospital-to-home, SNF-to-home, and ED follow-up workflows. Direct Transitional Care Management (TCM) support processes. Track 30-day and 90-day readmission risks and support mitigation activities. Ensure timely handoffs between Clinical Operations, PEC, and provider teams.
• Caregivation & Medication Management Support (10%): Oversee medication reconciliation workflows (post-discharge and routine). Support medication adherence interventions. Lead workflows for high-risk medication monitoring and escalation.
• Program Development & Quality Improvement (5%): Design and implement programs that improve patient experience, care transitions, SDOH resolution, and home-based outcomes. Collaborate with Clinical Operations Lead and Quality teams on improvement initiatives. Use data to identify gaps, track trends, and drive process changes.

Qualifications and Experience

• Bachelor’s Degree required in Nursing, Social Work, or related field
• Registered Nurse (RN) Required
• 5+ years’ experience in care coordination, LTSS, palliative care, or transitions of care
• Demonstrated leadership experience in interdisciplinary care teams