Manager, Complex Care and Advanced Illness Management

• Personal and financial wellness programs
• Opportunities for professional growth and career advancement
• Internal mobility and advancement opportunities
• Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals

• Provides clinical leadership and oversight for the Advanced Illness Management Team and Complex Care Management Team, ensuring delivery of high-quality, patient-centered care to individuals with serious illness, complex comorbidities, and high-risk profiles in the home setting.
• Oversees patient identification, risk stratification, and enrollment into AIM and other programs using clinical criteria, utilization trends, and predictive analytics to target appropriate high-risk populations.
• Facilitates and ensure timely goals-of-care discussions, advance care planning, and documentation of advance directives in collaboration with patients, families, and providers.
• Monitors and analyze clinical outcomes and quality metrics, including hospitalization and readmission rates, symptom control, patient experience, and length-of-stay trends; implement performance improvement initiatives based on findings.
• Provides clinical education, mentoring, and competency validation for AIM and Complex Care Management staff, promoting best practices in serious illness care, communication, and care transitions.
• Collaborates with physicians, hospitals, hospice and palliative care providers, and community partners to ensure seamless transitions of care across settings and timely escalation or de-escalation of services as appropriate.
• Conducts team audits on a routine basis in accordance with departmental policy.
• Assists staff in home care and the patient/member, family, physician, and home care team through education, evaluation, and decision making, as needed.
• Supports value-based care initiatives by aligning AIM and Complex Care interventions with organizational goals related to quality, cost containment, utilization management, and patient satisfaction.
• Participates in program development, evaluation, and expansion, including workflow design, clinical pathways, and documentation standards to enhance AIM and Complex Care service delivery.
• Performs all duties inherent in a managerial role. Ensures effective staff training, interviews candidates for employment, evaluates staff performance and conducts annual performance appraisal, and recommends hiring, promotions, salary actions, and terminations, as appropriate
• For Advanced Illness only: * Initiates conversations with the home care team regarding the potential need for Advanced Care Illness Planning. * Identifies potential barriers to Hospice and Palliative Care once member/patient agrees to advanced illness care. Follows up with clinical operations to communicate identified barriers and recommended interventions, as appropriate. * Leads huddles with team members to review status and qualifying criteria of cases in workflow; coordinates standard follow-up with both internal and external Hospices for referred cases. * Participates in special projects and performs other duties as assigned.

Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse, in NYS. required.

Education:
Bachelor's Degree in nursing from a state approved diploma program required. Master's Degree in nursing preferred.

Work Experience:
Minimum of three years of clinical experience required Experience in case management, administration or discharge planning experience in a hospital setting preferred Training in population care coordination preferred Exceptional customer service skills required Demonstrated ability to engage clinical counterparts in collaborative discussions required Strong follow up skills required, as well as the ability to manage multiple priorities required Proficiency in Microsoft Office Suite required Knowledge of value based care models and managed care preferred Hospice or palliative care experience preferred Experience as a patient advocate preferred For AIM only: Minimum of one year nursing experience in homecare or hospice required