Manager of Care Coordination and Home Health Nursing

Position Overview

Manager of Care Coordination and Home Health Nursing at the Center for Elders’ Independence.

Reporting to the Senior Director of Operational Excellence, the manager oversees care coordination and home health nursing within the PACE (Program of All-Inclusive Care for the Elderly) model, driving quality, efficiency, and compliance across clinical and operational teams.

$ – $, based on market, experience, and performance.

• Lead the Care Coordination Services Center and Home Health Nursing teams, ensuring efficient, high-quality participant-centered care.
• Supervise and support clinical and administrative staff, hiring, training, coaching, and performance evaluations.
• Collaborate with PACE leaders to develop strategies promoting care continuity, reducing hospitalizations and skilled nursing length of stay, improving health outcomes.
• Oversee coordination of participant care plans, ensuring seamless transitions between the PACE center, home health, skilled nursing facilities, and Residential Care for the Elderly facilities.
• Ensure appropriate delegation and management of home health services, including skilled nursing visits, chronic disease management, and post-acute follow-ups.
• Collaborate with interdisciplinary teams to develop, review, and modify care plans based on participant needs.
• Monitor and manage utilization of home health services and schedules to optimize efficiency and reduce unnecessary care costs.
• Ensure compliance with regulatory requirements, including CMS, DHCS, and California Board of Registered Nursing standards.
• Implement and monitor quality improvement initiatives to enhance clinical outcomes, participant satisfaction, and operational effectiveness.
• Participate in internal and external audits, ensuring thorough documentation and adherence to PACE program guidelines.
• Serve as the primary liaison between care coordination, home health nursing, and other departments to align care delivery processes.
• Communicate and collaborate effectively with care coordination services, home health nursing, IDT team, physicians, providers, and other leaders in the organization.
• Utilize data analytics to monitor performance, identify trends and areas for improvement.
• Prepare and present reports on key performance metrics, including hospital readmission rates, home health utilization, and participant outcomes.
• Leverage data to implement evidence-based interventions supporting continuous improvement initiatives.
• Possess strong clinical, leadership, and project management skills.
• Participate in departmental and organizational meetings.
• Maintain confidentiality of all procedures, results and participant information.
• Comply with all agency training requirements.
• Maintain a safe working environment by following CEI’s safety P&P’s.
• Maintain a courteous, helpful and professional attitude on the job.
• Perform other assigned duties, demonstrating flexibility and a positive proactive approach to participant care.

• Maintain eligibility for licensure by obtaining required continuing education units.
• Knowledge of safety hazards and precautions establishing a safe work and living environment.
• Ability to react calmly and effectively in emergency situations.
• Strong verbal and written communication skills to 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 and interdisciplinary team collaboration.
• Ability to work as a team player in a multicultural, multidisciplinary setting.
• Demonstrate 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, data analysis tools and Microsoft Office programs.
• Must have a valid California driver’s license, motor vehicle insurance and reliable transportation.

• Graduate from an accredited school of professional nursing.
• Bachelor of Science in Nursing (BSN) required;
  Master’s degree in Nursing, Healthcare…