Job Description:
Summary:
The Manager of Ambulatory Care Management and Care Coordination reports to AVP, Clinical Services and is responsible for the strategic and operational oversight of integrated care management programs across ambulatory settings. This role leads multidisciplinary teams supporting Chronic Care Management (CCM), Transitional Care Management (TCM), and care coordination services, with a focus on high-risk and rising-risk populations.
The Manager ensures seamless care transitions, longitudinal care management, and alignment with value-based care strategies to improve patient outcomes, enhance patient experience, and reduce total cost of care.
Key Responsibilities:Leadership & Program Oversight- Provide direct leadership to care management and care coordination teams, including staff supporting CCM, TCM, and high-risk patient programs
- Oversee daily operations of ambulatory care management services, ensuring integration across programs and consistency in workflows
- Partner with the AVP, Clinical Services to execute strategic priorities and scale care management capabilities
- Standardize protocols for patient outreach, enrollment, care planning, and documentation
Chronic Care Management (CCM) - Oversee development and execution of CCM programs for patients with multiple chronic conditions
- Ensure appropriate patient identification, enrollment, documentation standards, and ongoing engagement in CCM services
- Monitor care plan adherence, medication management, and preventive care compliance
Transitional Care Management (TCM) - Lead TCM workflows to support patients transitioning from inpatient or skilled nursing facilities to ambulatory care
- Ensure timely post-discharge outreach (e.g., 48-hour contact) and follow-up visit coordination
- Reduce avoidable readmissions through proactive care coordination and patient education
- Collaborate with inpatient teams and external partners to ensure smooth handoffs
Care Coordination & Population Health - Integrate CCM and TCM programs into a comprehensive care coordination model across ambulatory practices
- Support risk stratification and identification of high-risk, rising risk, and complex patients
- Ensure coordination across ambulatory care settings, acute care facilities, and community-based resources
- Promote patient-centered, culturally competent care delivery
Quality & Performance Management - Track and report key performance metrics, including readmissions, ED utilization, CCM/TCM enrollment and patient experience
- Identify gaps in care and implement targeted performance improvement initiatives
- Ensure compliance with value-based care contracts and quality benchmarks
Interdisciplinary Collaboration - Collaborate closely with physicians, advanced practice providers, practice managers, and department leadership
- Serve as a liaison between ambulatory operations and enterprise population health initiatives
Financial & Operational Management - Manage staffing models, productivity, and program budgets for care management services
- Drive optimization of reimbursement opportunities related to CCM, TCM, and care coordination services
- Identify opportunities to reduce total cost of care while improving outcomes
Staff Development & Engagement - Recruit, onboard, and mentor care management staff
- Establish clear performance expectations and conduct regular evaluations
- Promote ongoing education in care management best practices, value-based care, and patient engagement strategies
Regulatory Compliance & Best Practices - Ensure adherence to CMS guidelines and payer requirements for CCM and TCM programs
- Maintain current knowledge of industry trends, regulatory updates, and best practices in ambulatory care management
Requirements:
Education: - Bachelor's degree in nursing required
Experience:- 5+ years of experience in care management, care coordination, or population health
- 2-3 years of leadership experience preferred
- Experience in ambulatory care and value-based care environments preferred
Skills & Competencies:- Strong leadership and program management skills
- Deep understanding of CCM, TCM, and care coordination workflows
- Knowledge of value-based care models and population health strategies
- Proficiency with EHRs and care management platforms
- Data-driven decision-making and performance improvement expertise
- Excellent communication and stakeholder engagement skills
Licenses and Certifications:
- Active clinical license (RN) required
- Certification in Case Management (CCM) or related field preferred
Work Requirements:Shift: Day
On Call: No
Weekends: No
Travel Required: 25% Of Work Time
Shift Details: 8a-5p
City/State: Johnson City, TN
Location: Ballad Health Corporate
