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Vanova Health

CIN-backed management for independent physicians

Care Coordinator Manager

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeLivingston, NJ, USA

About the Job

Requirements

  • Active RN or LCSW licensure in New Jersey.
  • 5–7 years of experience in care coordination, case management, or a related clinical or population health role.
  • 3–5 years of program leadership experience, with a track record of leading teams through operational change or program growth.
  • Deep knowledge of Transitional Care Management (TCM) and complex care management best practices.
  • Commitment to patient-centered care and the ability to translate that commitment into team culture and practice.
  • Experience developing key performance indicators (KPIs) and performance frameworks in a clinical or population health setting.
  • Experience identifying and managing high-cost, high-utilizing patients, including strategy development and cross-functional coordination and execution.
  • Experience with population health platforms such as Arcadia, Innovaccer, or Lightbeam, and comfort leading technology onboarding and adoption.
  • Ability to synthesize complex data into clear, actionable insights for clinical and operational audiences.
  • Organizational, communication, and facilitation skills.

Responsibilities

  • Conduct and oversee Transitional Care Management outreach and follow-up for patients discharged from acute and post-acute settings.
  • Carry an active caseload focused on high-risk, high-utilizing, and complex patients.
  • Collaborate with primary care providers, specialists, behavioral health clinicians, and social workers to develop care plans informed by the treating team and ensure effective execution.
  • Partner with the Associate Chief Medical Officer to assess current operations and define a strategic vision for program growth and improvement.
  • Lead a comprehensive review of Transitional Care Management and complex care management workflows; identify gaps and develop refined protocols, training, and implementation plans.
  • Develop and implement a strategy for identifying and managing high-cost, high-utilizing patients through risk stratification, proactive outreach, and individualized care planning.
  • Develop and advance a behavioral health strategy by expanding internal roles, strengthening external provider partnerships, and identifying and implementing integrated care models and interventions.
  • Develop a social work strategy that uses population health data, social determinants of health screening, and risk stratification to deploy social work resources toward patients with the greatest intervenable need.
  • Establish and maintain a key performance indicator framework reflecting team performance, patient outcomes, and program impact; use data for continuous improvement and strategic decisions.
  • Expand care coordination services to additional clinically integrated network practices by building relationships, workflows, and infrastructure for onboarding and execution.
  • Recruit, onboard, supervise, and evaluate Care Coordinators, Care Coordination Specialists, Behavioral Health Specialists, Social Workers, and other staff.
  • Assess baseline team knowledge and develop plans to address skill gaps, standardize practice, and expand clinical scope.
  • Promote a patient-centered team culture through modeling, training, and accountability.
  • Provide ongoing coaching, performance feedback, and professional development.
  • Manage staffing levels, scheduling, and workload distribution to ensure adequate coverage and team sustainability.
  • Lead onboarding and optimization of a new population health platform in partnership with clinical, information technology, and data leadership and teams.
  • Use population health tools to monitor admission, discharge, and transfer data; identify care gaps; stratify risk; and drive targeted interventions.
  • Compile and present performance reports to leadership on Transitional Care Management, emergency department utilization, inpatient admissions, post-acute placements, and readmissions.
  • Use data where possible to inform program development, implementation, and evaluation.
  • Build and maintain relationships with health system care management and information technology teams to support effective care coordination for independent providers and practices.
  • Develop and sustain partnerships with post-acute providers, including skilled nursing facilities, home health agencies, and rehabilitation facilities, to support care continuity and reduce preventable hospital visits.
  • Cultivate and expand partnerships with external behavioral health providers, psychiatrists, and community mental health organizations to support integrated, accessible behavioral health care across the clinically integrated network.
  • Build a community-based organization and social service referral network to help the team address patients’ non-clinical and psychosocial needs at scale.
  • Represent care coordination in cross-functional and clinically integrated network-level meetings and contribute to broader population health strategy.
  • Ensure team adherence to regulatory requirements, clinical standards, and organizational policies.
  • Oversee documentation quality and support audits and quality assurance activities as needed.

Desired Qualifications

  • Certification in Case Management (CCM) or a related credential.
  • Experience in a value-based care, managed care, clinically integrated network, or health plan environment, with ability to build relationships and influence across an independent practice environment.
  • Familiarity with integrated behavioral health models and frameworks, including the Collaborative Care Model, co-location, and warm handoffs, and experience selecting and implementing an approach for a given practice environment.
  • Experience developing and executing a behavioral health strategy in a primary care, clinically integrated network, or population health setting, including evaluating and implementing integrated care models and building external provider partnerships.
  • Experience developing a proactive social work or social determinants of health strategy using population health data and screening tools.
  • Familiarity with social determinants of health screening tools such as PRAPARE and community resource platforms.
  • Experience with Medicare, Medicaid, or dual-eligible populations.
  • Experience expanding clinical programs across multiple practice sites.

About the Company

Vanova Health

CIN-backed management for independent physicians

Vanova Health serves independent physicians in New Jersey as a clinically integrated network that provides management services to support value-based care. It offers EMR, revenue cycle management, HR, financial, and compliance support to help practices run efficiently while staying independent. The network integrates data across member practices to streamline workflows and align with payors on value-based contracts. Its goal is to reduce total cost of care, improve access and patient engagement, and create shared value for physicians and payors through efficient operations and better outcomes.

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