Manager, Clinical Care Integration
CenterWell Senior Primary Care · Houston, TX
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Manager, Clinical Care Integration
@ CenterWell Senior Primary CareManager, Clinical Care Integration
About the job
CenterWell Senior Primary Care, part of Humana, provides personalized proactive care to seniors. The Manager oversees care teams, operational excellence, patient engagement, and community partnerships to ensure optimal health outcomes.
Requirements
- 5+ years nursing or case management
- Leadership experience
- Knowledge of chronic conditions
- Experience with care transitions
- Data analysis skills
Qualifications
- Active RN or LPN license
- Bachelor's degree preferred
- Ability to lead teams
- Strong clinical knowledge
- Excellent communication skills
Full job description
Become a part of our caring community
The Care Integration Team Manager is responsible for managing a team of nurses, care coaches, and social workers (referred to as “Care Integration Team or CIT) who engage high needs patients using an interdisciplinary team-based approach to ensure patients receive the individualized care and services they need to reach optimal health. The Manager provides direct oversight of market-based Care Integration Team operations, including care management program execution, team performance, staff development, and patient engagement. The Manager also maintains a direct caseload of high-risk patients while balancing leadership, operational, and strategic responsibilities. The Manager is responsible for building strong partnerships with clinical and operational market leaders on the Care Integration Team program and strategic opportunities for managing populations and coordinating care to improve patient outcomes and reduce avoidable acute and post-acute care utilization. The Manager role is hybrid with travel requirements to local clinics and communities (e.g., for market leader meetings, in-clinic case rounds, team member shadowing/coaching, home visit ride-along) and to preferred healthcare facilities in the community, alongside clinical market leader, to develop clinical partnerships for timely access to patient information, clinical collaboration on patient care, and patient centered resources.
As a guideline, this role involves spending 20% of the time on direct patient management, 70% of time on team management, operational excellence and program delivery, quality oversight, and staff development, and 10% of time on market relationships and community partnerships.
Major Duties and Responsibilities
Leads daily operations of the Care Integration Team, including productivity, quality, recruiting/hiring, training, and performance management.
Accountable for market Care Integration Team’s achievement of program goals and expectations across productivity, adherence to standard processes, clinical quality, patient engagement, utilization, and financial measures. Monitors and guides team performance using performance dashboards and metrics. Develops and implements action plans to meet goals.
Establishes clear performance expectations and holds Associates accountable through regular 1:1 feedback, audits / shadowing, SMART goals, coaching, and corrective action plans when needed. Builds team member capabilities through individual and group-based feedback and training sessions. Recognizes and celebrates strong performance.
Ensures clinical program integrity at the market level and addresses improvement opportunities, escalating to Clinical Care Integration Director as appropriate.
Interviews, hires, onboards, trains, and retains Care Integration Team associates.
Manages a caseload of high risk patients including performance of transitional and longitudinal care management, care planning, multidisciplinary case rounds, and patient home visits. Supports team members in reviewing patient cases, assessing drivers of utilization, and developing care plan recommendations for PCP review.
Partners with market leaders and key stakeholders to review performance and develop action plans to improve operational performance and reduce avoidable acute and post-acute care utilization. Prepares and leads regular market leader performance review meetings. Promotes collaboration and a "one care team” approach to optimize management of high-needs patients.
Builds and maintains relationships with community partners, including community health organizations, Centerwell organizations (home health and pharmacy), and health care systems for strong clinical collaboration to improve patient experience and population health outcomes.
Fosters a high-performing, engaged team culture that supports accountability, retention, professional growth, and recognition of achievements. Ensures team members understand how their work contributes to program goals.
Use your skills to make an impact
Required Qualifications
An active Registered Nurse, or Licensed Practice Nurse or Licensed Vocational Nurse, or PharmD licensure, or Emergency Medical Technician certification, or foreign equivalent of Registered Nurse or Medical Doctor license
5+ years of prior nursing, case management, or disease management experience
2+ years of leadership experience
Experience with transitions of care management and working with senior populations
Excellent clinical competencies, including knowledge of chronic conditions (e.g., Diabetes, CHF, COPD, CKD) and related symptoms, risk factors / signs of exacerbations, disease management interventions, and common medications
Experience working in primary care value-based / managed care organizations
Proficiency in analyzing and interpreting data trends
Comprehensive knowledge in Microsoft office products
Driving required to clinics and community organizations and health systems
Characteristics of the qualified candidate:
Pro-active, positive attitude, and comfortable being a change agent
Capable of identifying root causes of operational issues, problem-solving, and developing action plans
Capable of setting SMART goals, aligned with organization, and holding staff accountable for achieving goals.
Excellent communication skills, including follow-through communication and the ability to interpret and translate data to tell a story via executive level presentations.
A passionate advocate for improving clinician and patient experience and health outcomes through population health management.
Relationship management and negotiation skills to ensure key organizational and community partners feel engaged, heard, and respected.
Skilled at leading meetings with Medical and Operations Leaders, facilitating interdisciplinary discussions, and driving accountability across cross-functional teams.
Demonstrates resilience, adaptability, and professionalism in a fast-paced, evolving environment.
Knowledge of community resources, social determinants of health, and health equity strategies.
Preferred Qualifications
Knowledge of Athena (Electronic Medical Record) and Salesforce
Bilingual in English/Spanish with the ability to speak, read and write in both languages without limitations and assistance
Work at Home Statement
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About Us
About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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