CenterWell Senior Primary Care

Clinical Operations

• Partner with Primary Care Organization and CenterWell leadership to shape strategic direction and translate strategy into measurable business results
• Solve complex business problems and evaluate strategic opportunities
• Lead structured problem-solving and hypothesis-driven analyses using financial modeling, qualitative insights, and market research
• Summarize complex information into executive-ready presentations and recommendations for leadership and Board decision-making
• Evaluate strategic opportunities, feasibility, risks, and implementation considerations
• Own priority workstreams, including workplans, interdependencies, milestones, stakeholder alignment, and risk identification
• Facilitate cross-functional engagement through working sessions and stakeholder alignment activities
• Develop business cases, value analyses, KPI frameworks, and leadership updates
• Report to the Associate VP, PCO Strategy
• Support coordinated execution across the Primary Care Organization

Clinical Operations Strategy Lead

Physician

• Complete regular chart reviews and coordinate monthly meetings
• Serve as a resource for advanced practice providers to ensure quality patient care
• Collaborate with clinical leaders on quality of care, outcome data, procedures, and records issues
• Maintain a collaborative relationship with Nurse Practitioners
• Report to the Associate Director
• Provide virtual wraparound services supporting patients who cannot see their own PCP, including closing care gaps, ensuring timely medication access, and addressing urgent clinical needs

Collaborating Physician

Director

• Manage day-to-day branch operations and ensure operational efficiency, quality patient care, regulatory compliance, business development, patient-base growth, KPI achievement, and people management
• Supervise branch and clinical staff
• Ensure compliance with federal, state, and local certification and licensure requirements
• Lead long-range planning, fiscal viability, and branch quality of care
• Recruit, interview, and hire staff
• Monitor quality care and organizational performance
• Collaborate with clinical staff and branch administrators to coordinate patient care and ensure continuity, appropriateness, and quality of services
• Oversee onsite branch operations and maintain a safe, compliant work environment
• Monitor financial, clinical, and operational indicators; manage budgets and establish revenue goals
• Develop branch plans, performance action plans, and budgets with the Market Executive of Operations
• Partner with Sales on growth strategies, admission goals, and marketing initiatives
• Partner with Clinical leadership to improve patient outcomes and service quality
• Oversee chart audits, timely billing, continuous quality improvement, quarterly committee meetings, and patient satisfaction reviews
• Hire, train, supervise, and develop Clinical Managers and back-office associates
• Foster associate engagement, retention, productivity, and alignment with organizational values

Home Health Branch Director

Nurse Practitioner

• Call Humana members to discuss open care gaps and place needed orders, specifically for women who had a fracture in the last 6 months
• Create and register patient records within Athena
• Verify benefits
• Gather medication, medical, and surgical history
• Coordinate management of members' social needs, including providing transportation services

Operations

• Develop staffing plans, policies and procedures for the facility
• Lead implementation of staffing plans, policies and procedures
• Work closely with the Clinic Manager and dyad partner
• Identify and resolve complex technical and operational problems within departments
• Lead multiple managers or highly specialized professional associates
• Report directly to the Market President
• Support delivery of high-quality clinical support to patients

Associate Operations Director

Manager

• Support patients discharged from CenterWell Home Health services or those needing post-acute services
• Navigate healthcare options, post-acute care services, Medicare coverage, billing issues, and healthcare resources
• Provide patient options and education regarding sites of service, specialty offerings, post-acute care, and related questions
• Handle customer issues including location lookup, directions, and complaints
• Determine the appropriate clinical level of care using discussions, medical records, and other clinical data
• Match patient needs to service locations or provide alternative services when unavailable
• Advocate for customers throughout the referral process to ensure timely responses and maximize referral-to-admission conversion
• Follow up on and track referral and admission outcomes
• Support department performance objectives and patient satisfaction goals
• Assist with admissions as an ambassador for eligible patients
• Provide education regarding Home Health, Hospice, and Palliative Care Services
• Help with clinical eligibility review for alternate services
• Participate in special projects and perform other assigned responsibilities
• Complete mandatory HIPAA, Business Ethics and Compliance, and company policy training
• Report directly to the Manager, Care Management

Care Manager – Telephonic Nurse

Coach

• Support members’ optimal wellness by coordinating services and resources
• Identify and resolve barriers that hinder effective care
• Monitor patient care using assessments, data and conversations with members
• Ensure patients progress toward desired outcomes
• Apply professional concepts, standards, regulations, strategies and operating standards
• Make decisions regarding work approach and priorities while following direction
• Report directly to the Manager, Care Management

Telephonic Care Coach

Nurse

• Provide skilled nursing care to patients in their homes, including administering medications, performing wound care, and conducting patient assessments
• Develop and implement individualized care plans with physicians and other healthcare professionals
• Monitor patients' conditions and report changes
• Educate patients and families on disease management, medication, and treatment options
• Maintain accurate patient care records and coordinate with healthcare professionals
• Report patient care and condition progress to the patient's physician and Clinical Manager
• Oversee Home Health Aides and monitor appropriate completion of documentation
• Provide personalized one-on-one care to help patients regain independence at home

Registered Nurse, Home Health

Therapist

• Provide therapy services planned, delegated, and supervised by the qualified Occupational Therapist according to the patient's Plan of Treatment
• Assist with vocational and educational programs designed to restore, reinforce, and enhance task performance
• Design or adapt equipment and living or working environments; fabricate devices to improve function and independence
• Provide therapeutic treatment and instruction to improve or restore strength, coordination, range of motion, and function
• Report observations to the Occupational Therapist or Clinical Supervisor and document clinical information
• Prepare clinical notes and assist with progress reports
• Instruct patients and family members on home programs and adaptive equipment
• Participate in care coordination and discharge planning
• Design community reintegration activities and coordinate plans with the interdisciplinary team

Home Health Occupational Therapist Assistant – Per Diem

• Ensure continuity of care for patients transitioning into and out of services
• Serve as a CenterWell Home Health representative for discharged patients and patients needing post-acute services
• Navigate healthcare options, post-acute care services, Medicare coverage, billing issues, and healthcare resources
• Provide patient options and education regarding sites of service, specialty offerings, post-acute care, and related questions
• Handle customer issues including location lookups, directions, and complaints
• Determine the clinical level of care using discussions, medical records, and other clinical data
• Match patient needs to service locations or provide alternative services when needed
• Advocate for patients throughout the referral process
• Follow up on and track referral and admission outcomes
• Meet department performance objectives and patient satisfaction goals
• Assist with admissions by serving as an ambassador for eligible patients
• Place the right patient in the right care setting at the right time
• Complete mandatory HIPAA, business ethics, compliance, and company policy training
• Follow all company policies and procedures
• Educate patients about Home Health, Hospice, and Palliative Care Services
• Support clinical eligibility reviews for alternate services
• Participate in special projects and perform other assigned responsibilities
• Communicate with CenterWell Home Health clinical teams and facilitate patient follow-up
• Report directly to the Manager, Care Management

• Support patients discharged from CenterWell Home Health services or needing post-acute services
• Navigate healthcare options, post-acute care offerings, Medicare coverage, billing issues, and healthcare resources
• Provide patient options and education regarding sites of service, specialty offerings, post-acute care, and related questions
• Handle customer issues including location lookup, directions, and complaints
• Determine clinical level of care using discussions, medical records, and clinical data
• Match patients to appropriate service locations or provide alternative services
• Advocate for patients throughout the referral process
• Follow up on and track referral and admission outcomes
• Maintain department performance standards and patient satisfaction goals
• Assist with admissions by supporting patients who meet admission requirements
• Place the right patient in the right care setting at the right time
• Complete mandatory HIPAA, Business Ethics and Compliance, and company policy training
• Provide education about Home Health, Hospice, and Palliative Care Services
• Support clinical eligibility reviews for alternate services
• Participate in special projects and perform other assigned responsibilities
• Report directly to the Manager, Care Management
• Work a 40-hour, four-day schedule with rotating weekend and holiday coverage

Care Manager, Telephonic Nurse

Referral Specialist

• Report to the E-Referral Supervisor
• Monitor multiple e-referral systems to identify new referrals and manage alerts and notifications
• Monitor email requests to pull referrals from applicable referral systems
• Perform follow-up and manage related communication
• Scan documentation to determine patient eligibility for services, including service area, orders, and insurance
• Monitor the status of all referrals and follow up throughout the process
• Report referral status weekly
• Communicate with branch, sales, and leadership by email or phone regarding status updates and referral decisions
• Manage the ERST log daily with all referrals and ROCs decisions
• Maintain acceptable productivity levels according to work assignment and departmental standards
• Follow regulatory compliance areas, policies and procedures, and company best practices
• Serve as the initial contact point for clients or referral sources to promote continuity of care
• Collect and document referral information, manage compliance, and follow up on initial referral processes and decisions

E-Referral Specialist, Home Health

• Provide skilled nursing care to patients in their homes under the direction of an RN
• Implement individualized care plans with patients, families, and the healthcare team
• Educate patients and families on disease management, treatment options, and self-care techniques
• Maintain accurate documentation of patient visits, interventions, and outcomes
• Communicate promptly with patients, physicians, clinical managers, and healthcare team members regarding needs and status changes
• Participate in care coordination and discharge planning
• Support patients' recovery, rehabilitation, and independence in the home setting

Home Health Licensed Practical Nurse

• Guide, support, and educate clinicians
• Assist with goal setting, care planning, and clinical decision making
• Provide clinical support during operating hours
• Ensure clinical documentation, audits, and billing meet Medicare, payer, and company standards
• Monitor case management quality and outcomes
• Participate in hiring, training, performance evaluation, coaching, and corrective action for clinical staff
• Review and audit OASIS, visit notes, and plans of care for accuracy, completeness, and compliance
• Collaborate with field-based clinicians to ensure timely documentation submission and resolve deficiencies
• Assist with OASIS accuracy and validation
• Monitor outcome-based quality indicators and help develop performance improvement plans
• Participate in quality improvement projects, internal audits, and regulatory survey readiness
• Track and report quality metrics, trends, and improvement areas to leadership
• Provide staff education and support regarding compliance and documentation standards
• Stay current on federal and state home health regulations and quality assurance
• Provide limited direct patient care in exceptional or unplanned circumstances
• Work rotating on-call shifts
• Report to the Branch Director

Home Health RN Clinical Manager

• Manage day-to-day branch operations to ensure operational efficiency, quality patient care, regulatory compliance, business development, patient-base growth, KPI achievement, and people management
• Supervise branch and clinical staff
• Ensure compliance with federal, state, and local certification and licensure requirements
• Lead long-range planning, fiscal viability, and quality of care
• Recruit, interview, and hire staff
• Monitor quality care and organizational performance
• Collaborate with clinical staff and branch administrators to coordinate patient care and ensure continuity, appropriateness, and quality of services
• Oversee onsite branch operations and maintain a safe, compliant, and organized work environment
• Monitor financial, clinical, and operational indicators; manage budgets and establish revenue and budget goals
• Develop strategic branch plans, performance action plans, and budgets with the Market Executive of Operations
• Partner with Sales on growth strategies, admission goals, and marketing initiatives
• Partner with Clinical leadership to improve patient outcomes and service quality
• Oversee chart audits, timely billing, continuous quality improvement, quarterly committee meetings, and patient satisfaction reviews
• Hire, train, supervise, and develop Clinical Managers and back-office associates
• Foster associate engagement, retention, productivity, and alignment with organizational values
• Participate in periodic on-call rotation and travel up to 10% as needed

Clinical Operations Strategy Lead

Collaborating Physician

Home Health Branch Director

Nurse Practitioner

Associate Operations Director

Care Manager – Telephonic Nurse

Telephonic Care Coach

Registered Nurse, Home Health

Home Health Occupational Therapist Assistant – Per Diem

Care Manager – Telephonic Nurse

Care Manager, Telephonic Nurse

E-Referral Specialist, Home Health

Home Health Licensed Practical Nurse

Home Health RN Clinical Manager

Home Health RN Branch Director