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The Role The Care Integration Team Manager is responsible for managing a team of nurses, care coaches, and social workers (referred to as āCare 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,āÆthis 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.
Major Duties and ResponsibilitiesĀ
Leads daily operations of the Care Integration Team, including productivity, quality, recruiting/hiring, training, and performance management.Ā
Accountable for market Care Integration Teamās achievement of programĀ goalsĀ and expectationsĀ acrossĀ productivity,Ā adherence to standard processes,Ā clinicalĀ quality,Ā patient engagement,Ā utilization, and financial measures.Ā MonitorsĀ and guides teamĀ performance using performance dashboards and metrics.Ā Develops and implements action plans to meet goals.Ā
EstablishesĀ clearĀ performanceĀ expectationsĀ and holds Associates accountable throughĀ regularĀ 1:1Ā feedback, auditsĀ / shadowing, SMART goals, coaching, andĀ corrective action plans whenĀ needed.Ā Builds team member capabilities through individual and group-basedĀ feedbackĀ and training sessions.Ā Recognizes and celebratesĀ strong performance.Ā
Ensures clinical program integrity at the market level and addresses improvement opportunities, escalating to Clinical Care Integration Director asĀ appropriate.Ā
Interviews, hires, onboards, trains, andĀ retainsĀ Care Integration Team associates.Ā
Manages aĀ caseload ofĀ high riskĀ patientsĀ includingĀ performance ofĀ transitionalĀ and longitudinal care management,Ā care planning,Ā multidisciplinary case rounds,Ā andĀ patient home visits.Ā Supports team members in reviewing patient cases,Ā assessing drivers ofĀ utilization,Ā and developing care plan recommendations for PCP review.Ā
Partners with market leaders and key stakeholders toĀ reviewĀ performanceĀ andĀ develop action plansĀ to improve operational performanceĀ and reduceĀ avoidableĀ acute and post-acute careĀ utilization.Ā Prepares and leads regular market leader performance review meetings.Ā Promotes collaboration and a "one care teamā approach toĀ optimizeĀ management of high-needsĀ patients.Ā
Builds andĀ maintainsĀ relationships with community partners, including community health organizations,Ā CenterwellĀ organizations (home health and pharmacy), and health care systemsĀ for strong clinical collaborationĀ to improve patientĀ experience andĀ populationĀ health outcomes.Ā
Fosters a high-performing, engaged team culture that supports accountability, retention, professional growth, and recognition of achievements.Ā EnsuresĀ team members understand how their work contributes to program goals.Ā
Use your skills to make an impact
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Required QualificationsĀ
An active Registered Nurse,Ā orĀ Licensed Practice NurseĀ orĀ Licensed Vocational Nurse,Ā orĀ PharmDĀ licensure,Ā orĀ EmergencyĀ MedicalĀ TechnicianĀ certification, or foreign equivalent of Registered Nurse or Medical Doctor licenseĀ
5 + years of prior nursing, case management,Ā orĀ diseaseĀ managementĀ experienceĀ
2+ years ofĀ leadershipĀ experienceĀ
Experience with transitions of care management and working with seniorĀ populationsĀ
Excellent clinical competencies, including knowledge of chronic conditions (e.g., Diabetes, CHF, COPD, CKD)Ā and related symptoms,Ā risk factorsĀ /Ā signs of exacerbations,Ā disease management interventions,Ā and common medicationsĀ
Experience workingĀ inĀ primary care value-basedĀ / managedĀ care organizationsĀ
ProficiencyĀ in analyzing and interpreting data trendsĀ
Comprehensive knowledge in Microsoft office productsĀ
Must be passionate about contributing to an organization focused on continuously improvingĀ patientĀ experienceĀ
Must provide aĀ high speedĀ DSL or cable modem for home officeĀ
Must have a separate room with a locked door that can be used as home office to ensure you have absolute privacyĀ
DrivingĀ requiredĀ toĀ clinics andĀ community organizationsĀ andĀ health systemsĀ
Characteristics of the qualified candidate:āÆĀ
Pro-active, positive attitude, and comfortable being a change agentĀ
Capable ofĀ identifyingĀ root causes of operational issues, problem-solving, and developing action plansĀ
Capable of setting SMART goals, aligned with organization, and holding staff accountable for achieving goals.Ā
Excellent communication skills, including follow-through communication and the ability to interpret and translate data to tell a story via executive level presentations.Ā
A passionate advocate for improving clinician and patient experience and health outcomes through population health management.Ā
Relationship management and negotiation skills to ensure key organizational and community partners feel engaged, heard, and respected.āÆĀ
Skilled at leadingĀ meetings with Medical and Operations Leaders,Ā facilitatingĀ interdisciplinary discussions, and driving accountability across cross-functional teams.Ā
Demonstrates resilience, adaptability, and professionalism in a fast-paced, evolving environment.Ā
Knowledge of community resources, social determinants of health, and health equity strategies.Ā
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Preferred QualificationsĀ
Knowledge of Athena (Electronic Medical Record) and SalesforceĀ
Bilingual in English/Spanish with the ability to speak, read and write in both languages without limitations andĀ assistanceĀ
Additional Information
To ensure Home or Hybrid Home/Office employeesā ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:Ā
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.Ā
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Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
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Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, āHumanaā) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
About Us
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About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humanaās Primary Care Organization, which includes CenterWell Senior Primary Care, Convivaās innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health ā addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer atāÆCenterWell.com.ā
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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