Manager, Care Coordination, Full Time Days, Corporate Headquarters

Atlantic Health System (AHS) is seeking a Manager of Care Coordination within the Integrated Care division. This role provides strategic leadership, operational oversight, and clinical direction for organization-wide care coordination services spanning acute, ambulatory, and post-acute care settings.  

Reporting to the Executive Director of Care Coordination, the Manager collaborates closely with hospital leadership, Atlantic Medical Group (AMG), ACO leadership, post-acute partners, and community providers to ensure patients receive the right care, at the right time, in the right setting. This position supports five medical centers, Atlantic Medical Group, two accountable care organizations, and leads care coordination across Transitions of Care (TOC), Ambulatory Care Coordination (ACC), and Post-Acute Care (PAC) programs.  

A core focus of this role is optimization of post-acute care utilization, length of stay, and outcomes, supporting value-based care, readmission reduction, and safe, timely transitions across the continuum.  

• Provide operational and clinical leadership across multiple value-based financial risk contracts, population health initiatives, and integrated care programs throughout AHS.  

• Translate system strategy into executable workflows that align acute, ambulatory, and post-acute care coordination efforts.  

• Provide direct leadership and oversight for approximately 28 Complex Care Coordinators and Post-Acute Care (PAC) Liaisons across inpatient, ambulatory, and post-acute settings.  

• Partner with AMG and ACO leadership to implement strategic initiatives (e.g., Cardiometabolic Alliance) focused on high-risk and vulnerable populations.  

• Lead post-acute care coordination strategy, ensuring strong command of PAC workflows, discharge pathways, and care transitions to Skilled Nursing Facilities (SNFs), Home Health, High performing networks, Hospice, and Palliative Care.  

• Drive reduction in post-acute length of stay (LOS) through proactive care planning, early identification of barriers, and close collaboration with PAC partners.  

• Partner with SNF medical directors, SNFists, community physicians, and post-acute leadership to align clinical goals, escalation pathways, and discharge readiness.  

• Oversee PAC Liaisons embedded in high-volume SNFs, ensuring consistent engagement, timely patient follow-up, and alignment with AHS standards.  

• Monitor and optimize PAC network performance, including utilization patterns, readmissions from SNF, ED transfers, and avoidable acute escalations.  

• Collaborate with ACO and utilization management teams to support appropriate PAC placement, avoid over-utilization, and promote safe, timely transitions home.  

• Design, implement, and continuously refine care delivery models that support value-based care across the continuum, with particular emphasis on post-acute optimization and transitions management.  

• Ensure alignment with ACO contract requirements related to cost containment, quality metrics, and patient experience.  

• Lead and support targeted initiatives (e.g., HTN pilot with CV Service Line) to reduce readmissions, improve throughput, and enhance post-discharge outcomes.  

• Ensure high-risk patients with HRRP diagnoses (COPD, Pneumonia, AMI, CABG, CHF) receive timely, coordinated care across acute and post-acute settings to minimize CMS penalties and prevent avoidable readmissions.  

• Exercise independent clinical and operational judgment on a daily basis, managing complex patient care scenarios, staff escalation issues, and cross-departmental challenges.  

• Collaborate closely with AVNA Homecare & Hospice, Palliative Care, Mobile Integrated Health (MIH), and post-acute providers to ensure seamless transitions and patient advocacy.  

• Serve as a key operational and clinical leader within the High-Performing Network, particularly in the PAC space.  

• Ensure department priorities, workflows, and service standards are implemented consistently and effectively.  

• Monitor utilization trends (ED, inpatient, SNF, home health), identify opportunities for improvement, and implement population-based interventions.  

• Represent Care Coordination and PAC initiatives in meetings, committees, and presentations with hospital executives, physicia