Care Coordinator Manager

Vanova Health•Livingston, NJ

30d•$120,000 - $145,000•Hybrid

About The Position

The Manager of Care Coordination is a working manager role, with approximately 40% of time dedicated to direct care coordination activities and 60% to team supervision and management as well as program leadership and strategy. Reporting to the Associate Chief Medical Officer, the Manager leads Vanova Health's care coordination program through a period of meaningful growth and transformation — elevating current workflows, onboarding new population health technology, expanding services across the CIN, and building the external relationships necessary to support effective transitions of care. The ideal candidate is equally comfortable working alongside their team as they are setting direction, influencing stakeholders, and driving program-wide change.

Requirements

Active RN or LCSW licensure in New Jersey.
5–7 years of experience in care coordination, case management, or a related clinical or population health role.
3–5 years of program leadership experience, with a track record of leading teams through operational change or program growth.
Deep knowledge of TCM and complex care management best practices.
Genuine commitment to patient-centered care and the ability to translate that commitment into team culture and practice.
Experience developing KPIs and performance frameworks in a clinical or population health setting.
Experience identifying and managing high-cost, high-utilizing patients, including strategy development and cross-functional coordination and execution.
Experience with population health platforms (e.g., Arcadia, Innovacer, Lightbeam); comfort leading technology onboarding and adoption.
Ability to synthesize complex data into clear, actionable insights for clinical and operational audiences.
Excellent organizational, communication, and facilitation skills.

Nice To Haves

Certification in Case Management (CCM) or related credential.
Experience in a value-based care, managed care, CIN, or health plan environment. Ability to build relationships and influence across an independent practice environment.
Familiarity with integrated behavioral health models and frameworks (e.g., Collaborative Care Model, co-location, warm handoffs) and experience selecting and implementing the right approach for a given practice environment.
Experience developing and executing a behavioral health strategy in a primary care, CIN, or population health setting, including evaluating and implementing integrated care models and building external provider partnerships.
Experience developing a proactive social work or SDOH strategy using population health data and screening tools.
Familiarity with SDOH screening tools (e.g., PRAPARE) and community resource platforms.
Experience with Medicare, Medicaid, or dual-eligible populations.
Experience expanding clinical programs across multiple practice sites.

Responsibilities

Conduct and oversee Transitional Care Management (TCM) outreach and follow-up for patients discharged from acute and post-acute settings.
Carry an active caseload focused on high-risk, high-utilizing, and complex patients.
Collaborate closely with PCPs, specialists, behavioral health clinicians, and social workers to develop care plans and ensure they are informed by the treating team and effectively executed.
Partner with the Associate Chief Medical Officer to assess current operations and define a strategic vision for program growth and improvement.
Lead a comprehensive review of TCM and complex care management workflows; identify gaps and develop refined protocols, training, and implementation plans.
Develop and implement a strategy for identifying and managing high-cost, high-utilizing patients, including through risk stratification, proactive outreach, and individualized care planning.
Develop and advance a comprehensive behavioral health strategy — expanding internal roles, strengthening partnerships with external providers, and identifying and implementing integrated care models and interventions.
Develop a social work strategy that moves beyond reactive referral management — using population health data, SDOH screening, and risk stratification to deploy social work resources intentionally toward patients with the greatest intervenable need.
Establish and maintain a KPI framework that reflects team performance, patient outcomes, and program impact; use data to drive continuous improvement and inform strategic decisions.
Drive expansion of care coordination services to additional CIN practices, building the relationships, workflows, and infrastructure needed for successful onboarding and execution.
Recruit, onboard, supervise, and evaluate Care Coordinators, Care Coordination Specialists, Behavioral Health Specialists, Social Workers, and other staff.
Assess baseline team knowledge and develop plans to address skill gaps, standardize practice, and expand clinical scope.
Champion a patient-centered team culture through modeling, training, and accountability.
Provide ongoing coaching, performance feedback, and professional development.
Manage staffing levels, scheduling, and workload distribution to ensure adequate coverage and team sustainability.
Lead the onboarding, and optimization of a new population health platform (e.g., Arcadia, Innovacer) in partnership with clinical, IT, data leadership and teams.
Use population health tools to monitor ADT data, identify care gaps, stratify risk, and drive targeted interventions.
Compile and present performance reports to leadership on TCM, ED utilization, inpatient admissions, post-acute placements, and readmissions.
Utilize and leverage data where possible to inform program development, implementation, and evaluation.
Build and maintain relationships with health system care management and IT teams to drive effective care coordination on behalf of independent providers and practices.
Develop and sustain partnerships with post-acute providers — SNFs, home health agencies, and rehabilitation facilities — to support care continuity and reduce preventable hospital visits.
Cultivate and expand partnerships with external behavioral health providers, psychiatrists, and community mental health organizations to support integrated, accessible behavioral health care across the CIN.
Build a reliable community-based organization and social service referral network to support the team in addressing patients' non-clinical and psychosocial needs at scale.
Represent care coordination in cross-functional and CIN-level meetings, contributing to broader population health strategy.
Ensure team adherence to regulatory requirements, clinical standards, and organizational policies.
Oversee documentation quality and support audits and quality assurance activities as needed.