Lead, Clinical Support & Care Services

Homebase Medical•California, MO

About The Position

Homebase Medical is getting back to basics. Our mission is to optimize the quality of life for homebound older adults, allowing them to live independently and with dignity in their own homes. We make house calls – enabling access to quality wrap-around services for homebound older adults with complex health needs while improving the quality of their lives, right at home. We offer an array of medical and chronic care services and we’re backed by SCAN, a not-for-profit organization that has a history of supporting and improving the health and independence of older adults for over 45 years. Homebase Medical is getting back to basics. Our mission is to optimize the quality of life for homebound older adults, allowing them to live independently and with dignity in their own homes. The Lead, Clinical Support & Care Services leads the multi-disciplinary team responsible for all non-provider clinical support services, including care coordination, care planning, social determinants of health support, resource navigation, care transitions, symptom management, and medication management support. This leader ensures that patients receive timely, structured, protocol-driven follow-up care after their clinical visits—reducing avoidable utilization, closing gaps, and improving quality performance. The lead 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.

Requirements

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

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
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
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 Quality on gaps in care, outcome measures, and improvement opportunities. Interface 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 options. Foster a positive, collaborative, and high-performance team culture.