Manager, Complex Care and Advanced Illness Management

Visiting Nurse Service of New York d/b/a VNS Health • New York, NY

15d

About The Position

Manages the day-to-day activities of the Advanced Illness Management Program and the Complex Care Team. Provides clinical and operational leadership for the delivery of high-quality, patient centered care to individuals with advanced illness, complex chronic conditions and high-risk patients/members in the home care setting. Ensures the integration of evidence-based care practices into protocols, policies, consultation strategies, and continuous quality improvement initiatives. Supervises the team to ensure patients/members in the program meet eligibility requirements and appropriateness. Works under general supervision.

Requirements

• License and current registration to practice as a Registered Professional Nurse, in NYS. required.
• Bachelor's Degree in nursing from a state approved diploma program required.
• Minimum of three years of clinical experience required
• Exceptional customer service skills required
• Demonstrated ability to engage clinical counterparts in collaborative discussions required
• Strong follow up skills required, as well as the ability to manage multiple priorities required
• Proficiency in Microsoft Office Suite required
• Minimum of one year nursing experience in homecare or hospice required

Nice To Haves

• Master's Degree in nursing preferred.
• Experience in case management, administration or discharge planning experience in a hospital setting preferred
• Training in population care coordination preferred
• Knowledge of value based care models and managed care preferred
• Hospice or palliative care experience preferred
• Experience as a patient advocate preferred

Responsibilities

• Provides clinical leadership and oversight for the Advanced Illness Management Team and Complex Care Management Team, ensuring delivery of high-quality, patient-centered care to individuals with serious illness, complex comorbidities, and high-risk profiles in the home setting.
• Oversees patient identification, risk stratification, and enrollment into AIM and other programs using clinical criteria, utilization trends, and predictive analytics to target appropriate high-risk populations.
• Facilitates and ensure timely goals-of-care discussions, advance care planning, and documentation of advance directives in collaboration with patients, families, and providers.
• Monitors and analyze clinical outcomes and quality metrics, including hospitalization and readmission rates, symptom control, patient experience, and length-of-stay trends; implement performance improvement initiatives based on findings.
• Provides clinical education, mentoring, and competency validation for AIM and Complex Care Management staff, promoting best practices in serious illness care, communication, and care transitions.
• Collaborates with physicians, hospitals, hospice and palliative care providers, and community partners to ensure seamless transitions of care across settings and timely escalation or de-escalation of services as appropriate.
• Conducts team audits on a routine basis in accordance with departmental policy.
• Assists staff in home care and the patient/member, family, physician, and home care team through education, evaluation, and decision making, as needed.
• Supports value-based care initiatives by aligning AIM and Complex Care interventions with organizational goals related to quality, cost containment, utilization management, and patient satisfaction.
• Participates in program development, evaluation, and expansion, including workflow design, clinical pathways, and documentation standards to enhance AIM and Complex Care service delivery.
• Performs all duties inherent in a managerial role. Ensures effective staff training, interviews candidates for employment, evaluates staff performance and conducts annual performance appraisal, and recommends hiring, promotions, salary actions, and terminations, as appropriate
• Initiates conversations with the home care team regarding the potential need for Advanced Care Illness Planning.
• Identifies potential barriers to Hospice and Palliative Care once member/patient agrees to advanced illness care. Follows up with clinical operations to communicate identified barriers and recommended interventions, as appropriate.
• Leads huddles with team members to review status and qualifying criteria of cases in workflow; coordinates standard follow-up with both internal and external Hospices for referred cases.
• Participates in special projects and performs other duties as assigned.

Benefits

• Personal and financial wellness programs
• Opportunities for professional growth and career advancement
• Internal mobility and advancement opportunities
• Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals

What This Job Offers

• Job Type: Full-time
• Career Level: Manager