Leader, Clinical Support & Care Services (RN Required)

Homebase Medical is getting back to basics. Our mission is to optimize the quality of life for homebound older adults, allowing them to live independently and with dignity in their own homes.We make house calls - enabling access to quality wrap-around services for homebound older adults with complex health needs while improving the quality of their lives, right at home.

We offer an array of medical and chronic care services and we're backed by SCAN, a not-for-profit organization that has a history of supporting and improving the health and independence of older adults for over 45 years.

The Leader, Clinical Support & Care Services leads the multi-disciplinary team responsible for all non-provider clinical support services, including care coordination, care planning, social determinants of health support, resource navigation, care transitions, symptom management, and medication management support.

This leader ensures that patients receive timely, structured, protocol-driven follow-up care after their clinical visits-reducing avoidable utilization, closing gaps, and improving quality performance. The leader owns the infrastructure that surrounds the provider visit, enabling APP/NP clinicians to operate at the top of their license and ensuring continuity of care across settings.

Responsibilities include:

• Care Coordination & Care Planning (30%) Lead the team responsible for comprehensive care plan creation, updating, and documentation. Oversee identification and closure of care gaps across conditions, screenings, and preventive care. Coordinate interdisciplinary care teams (clinical, behavioral, social work, community resources). Manage high-risk patient workflows: follow-up, monitoring, and escalation.

• Advance Care Planning & Goals of Care (15%) Oversee facilitation of serious illness conversations and advance care planning discussions. Guide team in developing POLST forms, advance directives, and palliative support pathways. Ensure appropriate documentation and communication of patient preferences.

• DME, Home Health & LTSS Coordination (20%) Lead all DME ordering, tracking, and vendor coordination. Oversee Home Health referrals, follow-up, and completion confirmation. Manage LTSS navigation, including personal care services, home modifications, and waiver programs. Ensure efficient workflows for resource requests from field clinicians.

• Social Determinants of Health & Community Resources (10%) Lead SDOH screening, assessment, and intervention protocols. Manage community resource referral pathways (food, transportation, housing, caregiver support). Develop and maintain partnerships with community organizations and local resource providers.

• Care Transitions Management (10%) Oversee hospital-to-home, SNF-to-home, and ED follow-up workflows. Direct Transitional Care Management (TCM) support processes. Track 30-day and 90-day readmission risks and support mitigation activities. Ensure timely handoffs between Clinical Operations, PEC, and provider teams

• Medication Management Support (10%) Oversee medication reconciliation workflows (post-discharge and routine). Support medication adherence interventions. Lead workflows for high-risk medication monitoring and escalation

• Program Development & Quality Improvement (5%) Design and implement programs that improve patient experience, care transitions, SDOH resolution, and home-based outcomes. Collaborate with Clinical Operations Lead and Quality teams on improvement initiatives. Use data to identify gaps, track trends, and drive process changes

• Cross-Functional Integration Collaborate with PEC for scheduling-dependent care transitions and follow-up care. Partner closely with Manager of Clinical Provider Operations on visit-to-follow-up continuity and provider support. Coordinate with Clinical Quality on gaps in care, outcome measures, and improvement opportunities. Interface with Product/Tech to streamline workflows and documentation systems

• Support the implementation and adoption of AI-enabled tools such as intelligent call routing, conversational AI, and self-service member options.

• Foster a positive, collaborative, and high-performance team culture.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Qualifications and Experience:

• Bachelor's Degree requiredin Nursing, Social Work, or related field

• Registered Nurse (RN) Required

• 5+ years' experience in care coordination, LTSS, palliative care, or transitions of care.

• Demonstrated leadership experience in interdisciplinary care teams.

What's in it for you?

• PayScale information: $125,400 - $179,300

• Medical, Dental, Vision insurance

• Generous PTO and Holiday pay

• 401k with 5% safe harbor contribution

• Employee hardship fund

• Work-life balance

• And much more!

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At Homebase Medical we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

Homebase Medical is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.