Manager of Care Coordination and Home Health Nursing

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Licenses

RN License
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Driver's License
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Certifications

CPR Certification
(Required)

BLS Certification
(Required)

Do you have a valid CPR Certification certification?
Skills

Management
(Required)

Home health
(Required)

Geriatrics
(Required)
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Education

Bachelor of Science in Nursing
(Required)

Bachelor of Science
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Bachelor's degree

Master's degree

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Job details
Here’s how the job details align with your profile.
Job type

Full-time
 
Full job description
JOB DESCRIPTION

Manager of Care Coordination and Home Health Nursing

The Center for Elders’ Independence is a PACE (Program of All-Inclusive Care for the elderly) organization that uses an interdisciplinary team approach to care planning and care implementation for the purpose of providing high quality, affordable, integrated health care services to the elderly, and promoting autonomy, quality of life and the ability of individuals to live in their communities.

The Position:
Reporting to the Senior Director of Operational Excellence, the Manager of Care Coordination Services and Home Health Nursing is responsible for oversight, management, and continuous improvement of care coordination and home health nursing within the PACE (Program of All-Inclusive Care for the Elderly) model. This position ensures the delivery of high-quality, efficient and effective participant-centered care by collaborating with interdisciplinary teams, optimizing care transitions, and promoting effective communication and collaboration across clinical and operational departments and leaders. The Manager ensures compliance with all applicable regulatory standards and best practices, while driving initiatives to enhance operational efficiency and clinical outcomes.

Duties and Responsibilities:
Provides leadership and direction to the Care Coordination Services Center and Home Health Nursing teams, ensuring the delivery of efficient, high-quality, and participant-centered care.
Supervises and supports clinical and administrative staff, including hiring, training, coaching, and performance evaluations.
Collaborates with Senior Director of Operational Excellence and other PACE leaders to develop and implement strategies that promote care continuity, reduce hospitalizations and skilled nursing length of stays, to improve health outcomes.
Oversees the coordination of participant care plans, ensuring seamless transitions between the PACE center, home health and external care providers such as skilled nursing facilities and Residential Care for the Elderly facilities.
Ensures appropriate delegation and management of home health services, including skilled nursing visits, chronic disease management, and post-acute follow-ups.
Collaborates with interdisciplinary teams (IDT) to develop, review, and modify care plans based on participant needs.
Monitors and manages the utilization of home health services and schedules to optimize efficiency and reduce unnecessary care costs.
Ensures compliance with all regulatory requirements, including CMS, DHCS, and California Board of Registered Nursing standards.
Implements and monitors quality improvement initiatives to enhance clinical outcomes, participant satisfaction, and operational effectiveness.
Participates in internal and external audits, ensuring thorough documentation and adherence to PACE program guidelines.
Serves as the primary liaison between care coordination, home health nursing, and other departments to ensure alignment of care delivery processes.
Communicates and collaborates effectively with care coordination services, home health nursing, IDT team, physicians and providers and other leaders in the organization.
Utilizes data analytics to monitor care coordination and home health nursing performance, identify trends and areas for improvement.
Prepares and presents reports on key performance metrics, including hospital readmission rates, home health utilization, and participant outcomes.
Leverages data to implement evidence-based interventions that support continuous improvement initiatives.
Possesses strong clinical, leadership, and project management skills.
Participates in departmental and organizational meetings.
Maintains the confidentiality of all company procedures, results and information about participants or families.
Complies with all agency training requirements.
Maintains a safe working environment by following CEI’s safety PP’s.
Maintains a courteous, helpful and professional attitude on the job. Displays a willingness and ability to be responsive to all customer groups.
Performs other assigned duties, demonstrating flexibility and a positive proactive approach to participant care.
Requirements:

Maintains eligibility for licensure by obtaining required continuing education units.
Knowledge of common safety hazards and precautions to establish a safe work and living environment for participants.
Ability to react calmly and effectively in emergency situations.
Strong verbal and written communication skills to effectively interact with participants, families and team members.
Proven experience in care coordination, home health nursing, case management care within geriatric healthcare settings, with strong knowledge of PACE regulations, home health standards, and interdisciplinary team collaboration.
Ability to work as a team player in a multi-cultural, multi-disciplinary setting
Demonstrates ability to lead and develop care coordination and clinical teams effectively.
Excellent organizational, problem-solving, and decision-making skills.
Proficiency in using electronic health records (EHR), data analysis tools and Microsoft Office Programs.
Must have a valid California driver’s license, motor vehicle insurance and reliable transportation.
Qualifications:
Graduate from an accredited school of professional nursing.
Bachelor of Science in Nursing (BSN) required; Master’s degree in Nursing, Healthcare Administration, or related field preferred.
Current California Board of Registered Nursing License required.
Current CPR-BLS certification required.
Minimum of 5 years of nursing experience (acute, skilled nursing facility or ambulatory care working with the frail elderly population), with at least 3 years in leadership or management role.

The above job description is designed to provide an overview of the general function
intended to communicate the general function of the above-mentioned position and by no means shall be considered an exhaustive or complete outline of the specific tasks and functions that will be required. CEI reserves the right to change job descriptions, site assignments, and or work hours as required by the needs of the program. All employees are expected to perform their duties within their ability as required by the job and/or as requested by management.
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