Manager, Clinical Care Integration

CenterWell • Plant City, FL

9d • Hybrid

About The Position

The Care Integration Team Manager is responsible for managing a team of nurses, care coaches, and social workers (referred to as “Care Integration Team or CIT) who engage high needs patients using an interdisciplinary team-based approach to ensure patients receive the individualized care and services they need to reach optimal health. The Manager provides direct oversight of market-based Care Integration Team operations, including care management program execution, team performance, staff development, and patient engagement. The Manager also maintains a direct caseload of high-risk patients while balancing leadership, operational, and strategic responsibilities. The Manager is responsible for building strong partnerships with clinical and operational market leaders on the Care Integration Team program and strategic opportunities for managing populations and coordinating care to improve patient outcomes and reduce avoidable acute and post-acute care utilization. The Manager role is hybrid with travel requirements to local clinics and communities (e.g., for market leader meetings, in-clinic case rounds, team member shadowing/coaching, home visit ride-along) and to preferred healthcare facilities in the community, alongside clinical market leader, to develop clinical partnerships for timely access to patient information, clinical collaboration on patient care, and patient centered resources. As a guideline, this role involves spending 20% of the time on direct patient management, 70% of time on team management, operational excellence and program delivery, quality oversight, and staff development, and 10% of time on market relationships and community partnerships.

Requirements

• An active Registered Nurse, or Licensed Practice Nurse or Licensed Vocational Nurse, or PharmD licensure, or Emergency Medical Technician certification, or foreign equivalent of Registered Nurse or Medical Doctor license
• 5+ years of prior nursing, case management, or disease management experience
• 2+ years of leadership experience
• Experience with transitions of care management and working with senior populations
• Excellent clinical competencies, including knowledge of chronic conditions (e.g., Diabetes, CHF, COPD, CKD) and related symptoms, risk factors / signs of exacerbations, disease management interventions, and common medications
• Experience working in primary care value-based / managed care organizations
• Proficiency in analyzing and interpreting data trends
• Comprehensive knowledge in Microsoft office products
• Must be passionate about contributing to an organization focused on continuously improving patient experience
• Must provide a high speed DSL or cable modem for home office
• Must have a separate room with a locked door that can be used as home office to ensure you have absolute privacy
• Driving to clinics and community organizations and health systems

Nice To Haves

• Knowledge of Athena (Electronic Medical Record) and Salesforce
• Bilingual in English/Spanish with the ability to speak, read and write in both languages without limitations and assistance

Responsibilities

• Leads daily operations of the Care Integration Team, including productivity, quality, recruiting/hiring, training, and performance management.
• Accountable for market Care Integration Team’s achievement of program goals and expectations across productivity, adherence to standard processes, clinical quality, patient engagement, utilization, and financial measures.
• Monitors and guides team performance using performance dashboards and metrics.
• Develops and implements action plans to meet goals.
• Establishes clear performance expectations and holds Associates accountable through regular 1:1 feedback, audits / shadowing, SMART goals, coaching, and corrective action plans when needed.
• Builds team member capabilities through individual and group-based feedback and training sessions.
• Recognizes and celebrates strong performance.
• Ensures clinical program integrity at the market level and addresses improvement opportunities, escalating to Clinical Care Integration Director as appropriate.
• Interviews, hires, onboards, trains, and retains Care Integration Team associates.
• Manages a caseload of high risk patients including performance of transitional and longitudinal care management, care planning, multidisciplinary case rounds, and patient home visits.
• Supports team members in reviewing patient cases, assessing drivers of utilization, and developing care plan recommendations for PCP review.
• Partners with market leaders and key stakeholders to review performance and develop action plans to improve operational performance and reduce avoidable acute and post-acute care utilization.
• Prepares and leads regular market leader performance review meetings.
• Promotes collaboration and a "one care team” approach to optimize management of high-needs patients.
• Builds and maintains relationships with community partners, including community health organizations, Centerwell organizations (home health and pharmacy), and health care systems for strong clinical collaboration to improve patient experience and population health outcomes.
• Fosters a high-performing, engaged team culture that supports accountability, retention, professional growth, and recognition of achievements.
• Ensures team members understand how their work contributes to program goals.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed