Clinical Program Manager, Integrated Care - FT - Days - Integrated Care @ MV

El Camino Health is committed to hiring, retaining and growing the best and brightest professionals who will carry our mission and vision forward.  We are proud of our reputation in the community: One built on compassion, innovation, collaboration and delivering high-quality care.  Come join the team that makes this happen.

Applicants MUST apply for position(s) by submitting a separate application for each individual job posting number they are interested in being considered for.

FTE

1

Scheduled Bi-Weekly Hours

80

Work Shift

Day: 8 hours

Job Description

Form, lead, and facilitate cross-functional teams in the planning, development, coordination, and implementation of complex enterprise-wide inpatient and outpatient integrated care, post-acute, transitional care, and performance improvement initiatives. Coach and advise on efforts that improve efficiency, quality, patient outcomes, and patient experience.

Serve as the clinical leader for advancing care of designated patient populations throughout the organization and across the continuum of care, including acute, ambulatory, home, and post-acute settings.

With strategic focus on the CMS Transforming Episode Accountability Model (TEAM), bundled payment models, transitional care, and future value-based reimbursement initiatives, the role supports episode performance, transitions of care, post-acute network effectiveness, and measurable improvement in quality, utilization, patient outcomes, and patient experience.

Lead performance improvement initiatives through application of clinical expertise, knowledge of both clinical and administrative settings, and frequent interaction with clinical and non-clinical stakeholders.

Support responsible adoption of AI-enabled tools, analytics platforms, Epic enhancements, and emerging technologies that improve outreach, care coordination, documentation, and program performance.

Job Description

• Collaborates with leadership and cross-functional teams to improve evidence-based practice, clinical outcomes, patient experience, workflow efficiency, and program performance through performance improvement initiatives and gap analysis.
• Leads multidisciplinary teams across the enterprise to integrate best practices into clinical, operational, and transitional care workflows.
• Maintains current knowledge of clinical practice guidelines, regulatory requirements, specialty program operations, and emerging industry best practices.
• Oversees program data generation, analytics review, dashboard development, and presentation of performance results and recommendations to leadership.
• Concurrently monitors care delivery performance across inpatient, outpatient, home, and post-acute settings, identifying opportunities for intervention, education, and process improvement.
• Provides oversight of post-discharge follow-up workflows, outreach strategies, caregiver coordination, continuity of care, and timely follow-up processes for designated patient populations.
• Serves as a clinical liaison between hospital-based providers/acute care teams, patients, caregivers, primary care providers, physician offices, and post-acute partners to support safe and effective transitions of care.
• Oversees processes supporting medication reconciliation, therapy continuation, patient education, and continuity standards in collaboration with appropriate clinical teams.
• Serves as program lead for CMS TEAM workflows including beneficiary notifications, referral processes, compliance requirements, episode tracking, and operational readiness.
• Analyzes TEAM and related program trends including readmissions, emergency department returns, discharge disposition, length of stay, and post-acute utilization, recommending interventions to improve quality and financial performance.
• Leads implementation of TEAM care pathways in partnership with multidisciplinary teams (physician leadership, nursing leadership, rehabilitation, and Epic/IT).
• Supports implementation and optimization of care management technology, Epic workflows, AI-enabled tools, and digital solutions that improve outreach efficiency, risk stratification, and documentation quality.
• Educates stakeholders on effective use of approved technologies and workflow enhancements.
• Develops collaborative relationships with aligned skilled nursing facilities, home health agencies, physician offices, and community providers to improve post-acute outcomes and episode performance.
• Conducts onsite visits to post-acute partner facilities, as operationally appropriate, to strengthen collaboration, identify barriers, and support care transition performance.
• Conducts program and patient population reviews to