Manager of integrated care & referral services

Position Summary:

The Manager of Integrated Care & Referral Services coordinates and advances client navigation, referral management, and care coordination across the Social Care Network (SCN) and Community Care Hub. This position works closely with healthcare organizations, managed care organizations, community-based organizations, and other partners to strengthen referral pathways, improve access to services, and support seamless, whole-person care.

The Manager develops and improves workflows related to intake, referrals, benefits navigation, warm handoffs, care transitions, and care coordination. The role also supports partner engagement, operational improvement, data-informed decision-making, and regional and statewide efforts to strengthen integrated healthcare and social care services.

Reporting Structure:

Reports to: Director of Social Care Network
Dotted-line reports to: N/A
Direct reports: None
Exemption Status: Non-exempt

Essential Job Functions

Community Care Hub & Referral Operations

• Coordinate day-to-day Community Care Hub operations and referral workflows from intake through closure.
• Support timely referral assignment, tracking, follow-up, and closed-loop communication.
• Develop and improve processes that increase referral efficiency, partner engagement, and client outcomes.
• Collaborate with internal teams and community partners to identify and address referral barriers, service gaps, and capacity needs.
• Support alignment of referral pathways across healthcare, social care, and community-based organizations.

Integrated Care Coordination & Client Navigation

• Develop and support client-centered navigation and care coordination workflows, including intake, benefits navigation, assessment, care planning, and coordinated service delivery.
• Collaborate with navigators, healthcare providers, behavioral health organizations, and community partners to improve client experiences and continuity of care.
• Promote effective warm handoffs, wraparound services, and whole-person approaches that reduce barriers to care.
• Facilitate coordination among organizations serving shared clients.

Operational Improvement & Service Enhancement

• Evaluate workflows and recommend improvements that increase effectiveness, efficiency, consistency, and client engagement.
• Develop and maintain standard operating procedures for referral management, navigation services, and care coordination.
• Identify operational challenges and work with stakeholders to develop practical solutions.
• Support implementation of best practices and continuous improvement efforts that enhance service delivery and the client experience.

Documentation, Reporting & Readiness for Reimbursement

• Develop and maintain documentation practices that accurately capture care coordination activities, client outcomes, and service interventions.
• Support documentation standards for quality reporting, program evaluation, and future reimbursement opportunities.
• Monitor key performance measures and analyze referral and service data to identify trends, gaps, and opportunities for improvement.
• Prepare reports for leadership, funders, community partners, and other stakeholders.
• Support data-informed decision-making and continuous improvement efforts.

Partner Support & Technical Assistance

• Provide operational guidance and technical assistance to Community Care Hub participants, healthcare organizations, and community partners.
• Support onboarding, training, and ongoing education related to referral workflows, care coordination practices, and Community Care Hub operations.
• Serve as a trusted resource and organizational representative for referral management, integrated care coordination, client navigation, and Community Care Hub services.
• Facilitate communication and collaboration among participating organizations to strengthen coordination and service delivery.
• Communicate effectively with diverse audiences, including healthcare leadership, clinical staff, community-based organizations, frontline staff, clients, and families.

Community Engagement, Advocacy & Statewide Collaboration

• Represent GHN, the Social Care Network, and Community Care Hub initiatives in local, regional, and statewide meetings, workgroups, conferences, and collaborative efforts.
• Build relationships with healthcare organizations, community-based organizations, managed care organizations, and other stakeholders to strengthen referral pathways and integrated care.
• Support Community Care Hub growth and sustainability through partnership engagement, outreach, education, and sharing of best practices.
• Monitor emerging trends, policies, and opportunities related to Social Care Networks, Community Care Hubs, referral management, and integrated care coordination.

Compliance & Program Standards

• Adhere to HIPAA requirements and applicable privacy and security standards.
• Support compliance with contractual requirements, program standards, and organizational policies.
• Promote consistent and accurate documentation across referral and care coordination activities.
• Participate in continuous improvement efforts to enhance service delivery, referral outcomes, and client experience.

Preferred Qualifications

Education & Experience

• Bachelor’s degree in Public Health, Social Work, Healthcare Administration, Human Services, Community Health, Business Administration, or related field; an equivalent combination of education and experience may be considered.
• Three (3) years of experience in care coordination, healthcare operations, social services, community health, referral management, patient navigation, or a related field.
• Demonstrated ability to communicate and build rapport across organizational levels and community settings, adjusting communication style to the audience.
• Experience working with healthcare organizations, managed care organizations, community-based organizations, or social care initiatives preferred.
• Experience supporting collaborative partnerships and multi-sector initiatives preferred.
• Experience with referral management, client navigation, care coordination, or related platforms preferred.

Knowledge, Skills and Abilities:

• Knowledge of care coordination, referral management, client navigation, and health-related social needs.
• Understanding of healthcare, behavioral health, public health, and community-based service systems.
• Strong relationship-building, facilitation, partnership development, and communication skills.
• Strong organizational, project coordination, analytical, and problem-solving abilities.
• Ability to analyze operational data and identify opportunities for improvement.
• Understanding of trauma-informed, culturally responsive, and person-centered service approaches.
• Ability to work independently and collaboratively in a dynamic environment.
• Strong written, verbal, presentation, and public speaking skills.

Work environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The essential physical demands include frequent walking, standing, sitting for extended periods of time, writing/typing to fill out the required paperwork, speech, hearing, and vision is required for communication with co-workers, patients, and outside agencies. Work is predominantly inside and generally providing protection from weather conditions, but not necessarily from temperature changes.

Disclaimer

This job description is intended to provide an overview of the requirements of the position. As such, it is not necessarily all inclusive, and the job may require other essential and/or non-essential functions, tasks, duties, or responsibilities not listed herein. Management reserves the sole right to add, modify, or exclude any essential or non-essential requirement at any time with or without notice. Nothing in this job description, nor by the completion of any requirement of the job by the employee, is intended to create a contract of employment of any type. Employment is "at-will" and may be terminated at any time by the employee or employer with or without cause or notice.

* This position is eligible for a complete benefits package including medical, dental, vision, retirement, life insurance, and a generous paid holiday and PTO program.