CLINICAL MANAGER - INTEGRATED CARE

TeamCare Medical; Hempfield Township (Westmoreland County); On-site; USD 135,000 - 140,000; Full time

Benefits offered by this job

Paid time off

Paid holidays

Tuition reimbursement

403(b) retirement plan

Medical, dental, and vision coverage

HSA/HRA options

FSA

Transit and commuter benefits

Gym reimbursement

EAP

Job summary

Matter of Care Home Health Services seeks a Clinical Manager – Integrated Care to lead hospital-to-home transitions and develop individualized plans, partnering with physicians, discharge teams, and IDTs to reduce readmissions and improve outcomes.

The role supervises nurses and aides, conducts comprehensive in-home nursing assessments, educates patients and families on medications and chronic disease management, and ensures CMS/LHCSA compliance while traveling across assigned service areas.

Qualifications

• Required Active, unrestricted New York State RN license.
• Graduate of an accredited nursing program (BSN preferred).
• Minimum 3 years of clinical nursing experience.
• 1–2 years in home care, community health, or similar setting.
• Strong assessment, critical thinking, communication, and care coordination skills.
• Experience with EHR systems and ability to travel throughout assigned service areas.
• Preferred PACE, Care Transitions, Case Management, Long-Term Care, Geriatrics, and supervisory experience.

Responsibilities

• Lead hospital-to-home care transitions and develop individualized transition plans.
• Collaborate with hospital discharge planners, physicians, and interdisciplinary teams.
• Conduct comprehensive in-home nursing assessments and provide skilled nursing care.
• Educate participants and caregivers on medications, chronic disease management, and follow-up care.
• Serve as an active member of the Interdisciplinary Team (IDT).
• Supervise and mentor Nurses, Personal Care Aides, and Home Health Aides.
• Conduct supervisory field visits and competency assessments.
• Ensure compliance with PACE, LHCSA, CMS, and organizational standards.
• Participate in quality improvement initiatives and maintain accurate documentation.

Skills

Nursing leadership

Assessment

Critical thinking

Communication

Care coordination

Travel ability

EHR experience

Education

BSN preferred

Tools

EHR systems

Job description

Salary Range: $135,000.00 - $140,000.00 Monday-Friday | 8:30 AM-5:30 PM

Lead the Transition from Hospital to Home. Improve Lives Every Day.

At Matter of Care, we believe the most important moments in healthcare happen after a patient leaves the hospital. As a Clinical Manager – Integrated Care, you’ll play a vital leadership role in ensuring participants receive seamless, high-quality care as they transition safely home. This role partners with physicians, hospital discharge teams, home care clinicians, and interdisciplinary teams to reduce readmissions and improve outcomes.

What You’ll Do

• Lead hospital-to-home care transitions and develop individualized transition plans.


• Collaborate with hospital discharge planners, physicians, and interdisciplinary teams.


• Conduct comprehensive in-home nursing assessments and provide skilled nursing care.


• Educate participants and caregivers on medications, chronic disease management, and follow-up care.


• Serve as an active member of the Interdisciplinary Team (IDT).


• Supervise and mentor Nurses, Personal Care Aides, and Home Health Aides.


• Conduct supervisory field visits and competency assessments.


• Ensure compliance with PACE, LHCSA, CMS, and organizational standards.


• Participate in quality improvement initiatives and maintain accurate documentation.

What We’re Looking For

• Required Active, unrestricted New York State RN license.


• Graduate of an accredited nursing program (BSN preferred).


• Minimum 3 years of clinical nursing experience.


• 1–2 years in home care, community health, or similar setting.


• Strong assessment, critical thinking, communication, and care coordination skills.


• Experience with EHR systems and ability to travel throughout assigned service areas.


• Preferred PACE, Care Transitions, Case Management, Long-Term Care, Geriatrics, and supervisory experience.

Why Matter of Care?

• Monday-Friday daytime leadership schedule


• 28 Paid Time Off (PTO) days annually


• 9 Paid Holidays


• Tuition reimbursement up to $5,250 annually


• 403(b) retirement plan with employer contributions


• Medical, dental, and vision coverage


• Health Savings Account (HSA) and Health Reimbursement Account (HRA) options


• Flexible Spending Accounts (FSA)


• Transit and commuter benefits


• Gym reimbursement up to $400 annually


• Employee Assistance Program (EAP)


• Relias learning platform and professional development opportunities

About Matter of Care Home Health Services

Matter of Care is a member of the CenterLight Health System family and is dedicated to helping older adults receive high-quality, coordinated healthcare services while maintaining their independence and dignity. Through a participant-centered approach and strong community partnerships, we work every day to improve health outcomes and quality of life for the individuals and families we serve.

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): $135,000.00 - $140,000.00

Matter of Care Home Health Services is a New York State Department of Health licensed home care agency and supplemental staffing service that offers in-home care for the elderly, sick or homebound in the in the Bronx, Brooklyn, Queens, Manhattan, Nassau, and Westchester County.