CLINICAL MANAGER – INTEGRATED CARE – ALF

Matter of Care Home Health Services•New York, NY

3d•$135,000 - $140,000•Onsite

About The Position

At Matter of Care, we believe every older adult deserves the opportunity to age with dignity, independence, and the support they need to thrive in their community. We are seeking an experienced and compassionate Clinical Manager – Integrated Care – ALF to help coordinate high-quality, participant-centered care for older adults residing in assisted living settings. In this role, you’ll serve as a key clinical connection between Matter of Care, the assisted living facility, our participants and their families, and the interdisciplinary care team. You’ll combine hands-on nursing expertise with care coordination, clinical oversight, and relationship-building to help participants remain safe, supported, and as independent as possible.

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.
Strong assessment, critical thinking, communication, and care coordination skills.
Experience with EHR systems and ability to travel throughout assigned service areas.

Nice To Haves

PACE, Care Transitions, Case Management, Long-Term Care, Geriatrics, and supervisory experience.

Responsibilities

Conduct comprehensive nursing assessments, including UAS-NY assessments as assigned, and ongoing reassessments for participants residing in assisted living facilities.
Develop, implement, and monitor individualized care plans in collaboration with participants, families, assisted living staff, and the Interdisciplinary Team (IDT).
Monitor chronic and complex health conditions, identify changes in participant status, and coordinate timely interventions and provider notifications.
Perform skilled nursing visits, treatments, medication administration, and other clinical services as ordered and within the RN scope of practice.
Serve as the primary nursing liaison between Matter of Care and the assisted living facility, coordinating care with providers, specialists, pharmacy services, and other members of the care team.
Support safe transitions of care following emergency department visits, hospitalizations, and discharges, including medication reconciliation and follow-up on clinical orders, testing, and consultations.
Monitor medication effectiveness, adherence, side effects, interactions, and administration practices, collaborating with providers and pharmacy services to address concerns.
Assess, treat, and monitor wounds and skin conditions in collaboration with providers and wound care specialists.
Maintain timely and accurate clinical documentation and support compliance with CMS, New York State Department of Health, PACE, quality, safety, infection prevention, and incident-reporting requirements.
Educate participants, families, and caregivers; promote participant independence; and respond to urgent clinical changes by helping coordinate emergency services or a higher level of care when needed.