"Alerted.org

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, physicians, and system leadership.

+ Leverage analytics, dashboards, and performance reporting to guide care coordination strategy, PAC optimization, and return-on-investment evaluation.

Key Job Functions:

+ Leadership: Provide strategic direction, influence stakeholders, and drive outcomes across the care continuum.

+ Program Management: Design, implement, and sustain high-value care coordination and post-acute care programs.

+ Process Improvement: Lead continuous improvement, conflict resolution, and staff development initiatives.

+ Collaboration: Partner effectively with physicians, post-acute providers, healthcare teams, and community partners.

+ Independent Judgment: Demonstrate sound clinical and operational decision-making with accountability for outcomes.

+ Inclusivity: Foster an inclusive, collaborative culture across diverse teams and settings.

+ Communication: Exhibit strong written, verbal, presentation, and active listening skills.

+ Technical Proficiency: Proficient in Microsoft Office, including Excel; experience with care coordination platforms preferred.

+ Additional Duties: Perform other responsibilities as assigned by the Executive Director.

Education:

+ Graduate of an accredited Nursing Program; BSN required, CCM preferred.

+ Licensure: Active NJ RN license required; PA and NY licenses preferred.

Experience:

+ Minimum 5 years of management experience

+ 7–10 years of RN experience

+ Strong background in care coordination, transitions of care, post-acute care, utilization management, and population health preferred.

At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

+ Morristown Medical Center, Morristown, NJ

+ Overlook Medical Center, Summit, NJ

+ Newton Medical Center, Newton, NJ

+ Chilton Medical Center, Pompton Plains, NJ

+ Hackettstown Medical Center, Hackettstown, NJ

+ Goryeb Children's Hospital, Morristown, NJ

+ CentraState Healthcare System, Freehold, NJ

+ Atlantic Home Care and Hospice

+ Atlantic Mobile Health

+ Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:

+ 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years

+ Best Places to Work in Healthcare - Modern Healthcare

+ 150 Top Places to work in Healthcare - Becker's Healthcare

+ 100 Accountable Care Organizations to Know - Becker's Hospital Review

+ Best Employers for Workers over 50 - AARP

+ Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

+ One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine

+ One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine

+ Official Health Care Partner of the New York Jets

+ NJ Sustainable Business

Atlantic Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:

Team Member Benefits

+ Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)

+ Life & AD&D Insurance.

+ Short-Term and Long-Term Disability (with options to supplement)

+ 403(b) Retirement Plan: Employer match, additional non-elective contribution

+ PTO & Paid Sick Leave

+ Tuition Assistance, Advancement & Academic Advising

+ Parental, Adoption, Surrogacy Leave

+ Backup and On-Site Childcare

+ Well-Being Rewards

+ Employee Assistance Program (EAP)

+ Fertility Benefits, Healthy Pregnancy Program

+ Flexible Spending & Commuter Accounts

+ Pet, Home & Auto, Identity Theft and Legal Insurance

____________________________________________

Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.

EEO STATEMENT

Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.