Manager of Integrated Care & Referral Services

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.

Reports to:

Director of Social Care Network

Dotted-line reports to: N/A

Direct reports:
None

Exemption Status:
Non-exempt

Job Level: Individual Contributor

• 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.

• 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.

• 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.

• 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.

• 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.

• Represent GHN, the Social Care Network, and Community Care Hub initiatives in local, regional, and statewide meetings, work groups, 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…