Mgr, Transitions of Care at ConcertoHealth
Detroit, MI, US

Job Details




Concerto Health is an Aliso Viejo, CA-based company with one vision: to redesign primary health care delivery for millions of people with complex health needs. The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with all aspects of the health care delivery system. Whether you’re a patient, provider, or health plan, the Concerto Health Primary Care Support Platform can help.

The Concerto Health care model changes everything – payment, staffing, processes, IT systems, and culture. Our model surrounds patients, families, caregivers, and provider groups with a multi-disciplinary team of health professionals and systems of care. Our innovative team-based approach to care delivers unparalleled results in the areas of patient/staff experience, transitions of care, quality, and cost reduction, while simultaneously fostering a culture that humanizes health care delivery for those most in need.

We currently operate in 2 markets (Michigan and Washington) that include 7 primary care practices and 3 field-based teams, in partnership with innovative health plans and provider groups that share our vision.

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The Manager of Concerto’s Transition of Care Program reports to the VP, Integrated Care Initiatives and is responsible for the oversight, management and implementation of Concerto’s Transition of Care (TOC) Program. This position ensures that all staffing, processes, programs and operations of TOC are fully implemented. The TOC Program is key to ensuring the safe and successful transition of members across the care continuum. The Manager facilitates interdisciplinary collaboration and ensures safe transitions to appropriate care to mitigate the risk of inpatient readmissions and/or emergency department visits. 


The position is responsible for collaborating with both the Utilization Management, Care Management, Quality and other cross functional areas and teams to ensure effective TOC program operations. The Manager is responsible for all monitoring compliance and internal data, TOC reporting and all TOC program activities.


In addition, this position is responsible for recruitment, hiring, training, development and retention of the Transition of Care Coaches. The physical location for this position must be in Michigan as all frontline leadership must be physically located in the Michigan market in order to support Michigan product lines.



  • Implements TOC programs, policies and procedures to ensure that all functions meet internal, Health Plan, and Regulatory requirements.
  • Participates in the identification of members needing assistance with transitions of care and distribution of cases to the TOC Coaches.
  • Participates in multidisciplinary rounds and field team meetings with other members of the care team.
  • Implements, monitors and ensures the TOC program meets regulatory and accrediting requirements as well as health plan Model of Care requirements.
  • Travel throughout Michigan to shadow, mentor, and lead all TOC Coaches and to work with provider and health partners to continuously improve the TOC program.
  • Monitors all program data and metrics, including but not limited to cost, quality, and utilization metrics, focusing on inpatient readmissions and the timeliness of and completion of all required inpatient and post discharge care activities (e.g., assessments, care plans, Interdisciplinary Care Team (ICT)s, medication reconciliation, provider appointments, etc.)
  • Ensures staff competency utilizing internal record audit and participation in clinical rounds
  • Ensures that members receive appropriate authorizations and access to services and appointments post discharge
  • Collaborates with all members of the CM and Corporate leadership team to identify opportunities for process improvement that are consistent with the organization’s vision and strategic long-term goals
  • Communicates with the staff both verbally and in writing to convey health plan, contract, or operations information to ensure all staff members have a consistent and appropriate knowledge base to perform their duties
  • Promotes staff growth and development by identifying educational opportunities to increase efficiency and maintain compliance with industry standards
  • Participates in the collection, analysis, and reporting of data relevant to the TOC program to internal and external parties
  • Responsible for recruitment and selection of staff. Responsible for orientation of new staff, on-going training, mentoring, and performance reviews
  • Conducts staff meetings, assuring policy and procedures are adhered to and when necessary, modified to address changing strategic objectives
  • Develop and maintain collaborative relationships with other internal market leaders, payor partners, regulators, and corporate teams
  • Promote a positive work environment, set an atmosphere of open communication and feedback
  • Hold staff to high standard of execution operationally
  • Manage staff productivity by developing and monitoring operational reports
  • Evaluate and escalate concerns that have potential patient impact
  • Embodies joy in work, leads initiatives that achieve best-in-class team experience
  • Performs other job-related duties as assigned



  • Minimum of 5 years experience in a clinical setting.
  • Bachelor's degree (B.A. or B.S., BSN) is preferred from a four-year college or university and/or comparable work experience.
  • Valid/current RN license in state of practice.
  • Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines
  • Comfort embracing and navigating ambiguity.
  • A creative problem solver with a proven track record of successful implementation of transition of care programs
  • Flexibility and fluidity in managing many responsibilities
  • Strong communication and presentation skills with the ability to collaborate and work with multiple stakeholders
  • Strong analytical, quantitative and operational skills
  • Project management experience, including expertise in the development and management of project plans
  • Strong interpersonal and critical-thinking skills.
  • Proven track record of leading and building teams to drive measurable results
  • Self-directed and committed to continuous improvement of processes and procedures
  • Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines
  • Excellent planning and organization skills
  • Comfort embracing and navigating ambiguity.
  • Ability to operate effectively in a high-growth, high-performance culture
  • Knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid/Medicare programs and dual eligible populations, and benefit systems is preferred.
  • Knowledge of Medicare regulations and programs related to transitions of care.
  • Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care.
  • Strong interpersonal communication and negotiation skills.
  • Strong clinical skills including an understanding of and ability to implement evidenced-based care.
  • Strong organizational and time management skills.
  • Willingness to travel 25% of the time
  • Average to advanced computer & software skills (Microsoft Word, Excel, Outlook)