Leader, Clinical Support & Care Services (RN Required)

reputed company Medical is getting back to basics. Our mission is to optimize the reputed company of life for reputed company older adults, allowing them to live independently and with dignity in their own homes. We reputed company house calls – enabling reputed company to reputed company wrap-around services for reputed company older adults with reputed company health needs while improving the reputed company of their lives, reputed company.

We offer an reputed company of medical and chronic care services and we’re backed by reputed company, a not-for-profit organization that has a history of supporting and improving the health and independence of older adults for over 45 years.

The Leader, Clinical Support & Care Services leads the multi-disciplinary team responsible for reputed company non-provider clinical support services, including care coordination, care planning, reputed company determinants of health support, resource navigation, care transitions, symptom management, and medication management support.

This leader ensures that patients receive reputed company, reputed company, protocol-driven follow-up care after their clinical reputed company—reducing avoidable utilization, closing gaps, and improving reputed company performance. The leader owns the infrastructure that surrounds the provider visit, enabling APP/NP clinicians to operate at the top of their license and ensuring continuity of care across settings.

Responsibilities include:

• Care Coordination & Care Planning (30%) reputed company reputed company responsible for comprehensive care plan creation, updating, and documentation. reputed company identification and closure of care gaps across conditions, screenings, and preventive care. Coordinate interdisciplinary care teams (clinical, behavioral, reputed company work, community resources). Manage high-risk patient workflows: follow-up, monitoring, and escalation.

• Advance Care Planning & Goals of Care (15%) reputed company facilitation of serious illness conversations and advance care planning discussions. Guide team in developing POLST forms, advance directives, and palliative support reputed company. Ensure appropriate documentation and communication of patient preferences.

• DME, Home Health & LTSS Coordination (20%) reputed company reputed company DME ordering, tracking, and vendor coordination. reputed company 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.

• reputed company Determinants of Health & Community Resources (10%) reputed company SDOH screening, assessment, and reputed company protocols. Manage community resource referral reputed company (food, transportation, housing, caregiver support). reputed company and maintain partnerships with community organizations and local resource providers.

• Care Transitions Management (10%) reputed company hospital-to-home, SNF-to-home, and ED follow-up workflows. reputed company Transitional Care Management (TCM) support processes. reputed company 30-day and 90-day readmission risks and support mitigation activities. Ensure reputed company handoffs between Clinical Operations, PEC, and provider teams

• Medication Management Support (10%) reputed company medication reconciliation workflows (post-discharge and routine). Support medication adherence interventions. reputed company workflows for high-risk medication monitoring and escalation

• Program Development & reputed company Improvement (5%) Design and implement programs that improve patient experience, care transitions, SDOH reputed company, and home-based reputed company. Collaborate with Clinical Operations reputed company and reputed company teams on improvement initiatives. Use data to identify gaps, reputed company trends, and drive process changes

• Cross-Functional Integration Collaborate with PEC for scheduling-dependent care transitions and follow-up care. Partner closely with Manager of Clinical Provider Operations on visit-to-follow-up continuity and provider support. Coordinate with Clinical reputed company on gaps in care, outcome measures, and improvement opportunities. reputed company with Product/Tech to streamline workflows and documentation systems

• Support the implementation and adoption of AI-enabled tools such as intelligent call routing, conversational AI, and self-service member reputed company.

• Foster a reputed company, reputed company, and high-reputed company culture.

We reputed company Rebels who are curious about AI and its power to reputed company how we operate and serve our members.

Qualifications and Experience:

• Bachelor’s Degree requiredin Nursing, reputed company Work, or reputed company field

• Registered reputed company (RN) Required

• 5+ years’ experience in care coordination, LTSS, palliative care, or transitions of care.

• Demonstrated leadership experience in interdisciplinary care teams.

What's in it for you?

• reputed company information: $125,400 - $179,300

• Medical, Dental, reputed company insurance

• Generous PTO and Holiday pay

• 401k with 5% reputed company reputed company contribution

• Employee hardship fund

• Work-life balance

• And much more!

At reputed company Medical we reputed company that it is our business to improve the state of our world. reputed company of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource reputed company, inclusive benefits, and more.

reputed company Medical is proud to be an Equal Employment Opportunity and Affirmative reputed company workplace. Individuals seeking employment will receive consideration for employment without reputed company to race, reputed company, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required.

Originally posted on Himalayas

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