Job Purpose:
The Clinical Manager – Integrated Care plays an essential role in ensuring that participants in contracted organizations experience smooth and effective transitions from hospital to home, helping to reduce hospital readmissions and improve health outcomes. This role provides direct care, participant education, and coordinates with interdisciplinary teams (IDT) to enhance participant outcomes during the post-discharge period. The Clinical Manager also supervises home care staff, ensures compliance with clinical standards, and ensures that participants receive appropriate, high-quality care at home.

This position combines oversight of the clinical care of contracted organizations provided at participants' homes with leadership in care transition planning and execution. The Clinical Manager collaborates with hospital discharge planners, physicians, and home care staff to create and implement personalized care plans for participants, ensuring their health needs are met in alignment with organizational goals and best practices.

Job Responsibilities:

Care Transition Oversight:

• Collaborate with hospital discharge planners, physicians, and interdisciplinary teams to develop personalized care transition plans for participants discharged from hospital to home.
• Review participants' medical histories, discharge instructions, medications, and follow-up care to ensure smooth, safe transitions.
• Ensure that participants understand their post-discharge care plan and provide education on medication management, wound care, and follow-up appointments.

Participant Assessments and Care Coordination:

• Conduct comprehensive home visits to assess participants' health, living environment, and support systems.
• Monitor participants’ conditions during the transition period, identifying any changes or complications that require adjustments to the care plan.
• Work with the IDT to ensure comprehensive care coordination and optimize participant outcomes.

Direct Nursing Care:

• Provide skilled nursing services in the home, including medication administration, wound care, vital sign monitoring, and support with activities of daily living.
• Educate participants and families on managing chronic conditions, preventing complications, and improving overall health outcomes.
• Identify early signs of health deterioration and take proactive measures to prevent readmissions.

Supervision and Field Support:

• Supervise, instruct, and guide Nurses, Personal Care Aides (PCAs), and Home Health Aides (HHAs) in the delivery of home health care services.
• Conduct joint visits with Nurses and other field staff for supervision and competency assessments.
• Provide mentorship and guidance, acting as a resource for nursing staff and care teams.
• Monitor adherence to care plans and clinical training protocols, addressing deficiencies when needed in coordination with leadership.

Quality and Compliance:

• Maintain accurate, up-to-date documentation of participant assessments and care provided, ensuring compliance with PACE, LHCSA regulations, and organizational standards.
• Participate in quality improvement initiatives and conduct routine audits to ensure quality care delivery.
• Stay informed about current health-related issues, evidence-based clinical practices, and regulatory changes.

Managerial Oversight and Team Collaboration:

• Ensure that all clinical team members are adequately trained and provide high-quality care according to best practice standards.
• Coordinate with the Care Planning Team to develop and implement care plans based on participant assessments and goals.
• Participate in mandatory in-service education and staff development programs.
• Support the training department in developing orientation programs for new hires and staff members.

Participant and Family Education:

• Educate participants and families about care plans, including medication management, lifestyle modifications, and safety precautions.
• Empower participants to manage their health and understand when additional care is needed.
• Address participant-specific concerns related to transitioning from hospital to home.

Physical and Cognitive Requirements:

• Ability to lift up to 50 pounds, bend, squat, and perform other physical tasks as required for patient care and equipment handling.
• Ability to perform administrative duties such as typing and documentation on a computer.
• Cognitive ability to make decisions, reason, analyze information, and apply knowledge in clinical settings.
• Ability to travel between locations, walk to participants' homes, and work in varied environmental conditions, including outdoor and patient home settings.

Schedule: 8:30 AM – 5:30 PM
Weekly Hours: 40

Qualifications:

• Education: Degree from an NLN-accredited nursing school (RN, BSN preferred).
• Experience: At least 3 years of clinical nursing experience, including 1-2 years in home care or a similar healthcare setting. Experience in care transitions, case management, or PACE programs preferred.
• Licensure: Current active and unrestricted license as a Registered Nurse in New York State.
• Skills: Strong clinical assessment and critical thinking abilities, excellent communication skills, and the capacity to manage multiple participant cases effectively.

Additional Requirements:

• Ability to travel to participants’ homes and work in varying environmental conditions.
• Proficiency with computers and electronic health record (EHR) systems.
• Experience with long-term care or managed care systems beneficial.
• Vehicle and current New York State driver's license preferred.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull—Up to 50 pounds of equipment, baggage, supplies, and the ability to lift patients safely and using OSHA guidelines, etc.
• Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. The position requires the individual to be able to travel and walk between sites/locations and work areas throughout the day.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually assess patients, read orders, type/write documentation, etc., with accuracy.
• Audio Hearing and Motor Skills (Language) Requirements—The candidate Must be able to listen attentively, document information from patients, community members, providers, etc., and accurately process intake information through audio processing. In addition, the candidate must be able to speak comfortably and clearly with language and motor skills so that customers can understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max):

Salary : $135,000 - $140,000