Community Nurse Case Manager (RN)

ChenMed•Normandy, MO

21d•Onsite

About The Position

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team. The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) who works with our highest complexity patients, their primary care physicians, and other members of the care team that provides hyperfocus case management and field nursing interventions to prevent unnecessary hospital arrivals, keep patients engaged in our intensive primary care model and maximize their healthy time at home. The Intensive Community Managers (ICCMs) will serve as a clinical lead for the Complex Care Team. They will assess, evaluate, and coordinate the team’s efforts to stabilize our highest risk patients, with special areas of focus including safe transitions of care from facilities back to our primary care teams, stabilization of our highest risk ambulatory patients and outreach to patients who are assigned to us but are not engaged in care. This person will perform assessments and design comprehensive plans of care, and drive the actions needed to keep the most complex patients safely at home. This professional will also provide clinical supervision to other team members in delivering the plan of care and in other tasks necessary to meet their needs and engage them in care. As a clinical leader for the team, this person will also be deeply involved in prioritizing team efforts and may also become the direct supervisor for some team members. The Intensive Community Manager works in partnership with the PCPs to draft personalized care plans that address patient’s immediate needs that cause a risk for unnecessary hospital arrivals. This position adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

Requirements

Registered Nurse (RN)
Experience working with highest complexity patients
Experience in case management
Experience in field nursing interventions
Experience in transitions of care from facilities back to primary care teams
Experience in stabilization of high-risk ambulatory patients
Experience in outreach to unengaged patients
Ability to perform assessments and design comprehensive plans of care
Ability to drive actions needed to keep complex patients safely at home
Ability to provide clinical supervision to team members
Ability to prioritize team efforts
Ability to work in partnership with PCPs
Ability to draft personalized care plans
Adherence to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.
Experience performing clinical and Social determination of Heath screening (SdoH) assessments
Experience with disease-oriented assessment and monitoring
Experience with medication monitoring
Experience with health education and self-care instructions in the outpatient in home setting.
Experience coordinating the Plan of Care
Experience overseeing Licensed Practical Nurses (LPNs)
Experience conducting/coordinating initial case management assessments
Experience completing individual plans of care with patients, family/caregivers, and care team members
Experience communicating instructions and methodologies
Experience assessing the environment of care (safety and security)
Experience assessing caregiver capacity and willingness to provide care
Experience assessing patient and caregiver educational needs
Experience coordinating, reporting, documenting, and following up on multidisciplinary team meetings.
Experience helping patients navigate healthcare systems
Experience connecting patients with community resources
Experience orchestrating multiple facets of healthcare delivery
Experience assisting with administrative and logistical tasks.
Experience coordinating the delivery of services to effectively address patient needs.
Experience facilitating and coaching patients in using natural supports and mainstream community resources.
Experience maintaining ongoing communication with families, community providers and others.
Experience establishing a supportive and motivational relationship with patients.
Experience monitoring the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Experience assisting patients and families with access to community/financial resources.
Experience referring cases to social workers as appropriate.
Ability to perform home visits under the direction of the patient’s primary care physician.

Nice To Haves

Innovative and entrepreneurial minded
High work ethic and ambition
Inspires others with kindness and joy

Responsibilities

Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital .
Provides home visits to perform initial assessment of patient and the development of care plan as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
Completes individual plan of cares with patients, family/care giver and care team members.
Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
Assesses the environment of care, e.g., safety and security.
Assesses the caregiver capacity and willingness to provide care.
Assesses patient and caregiver educational needs.
Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
Coordinates the delivery of services to effectively address patient needs.
Facilitates and coaches’ patients in using natural supports and mainstream community resources to address supportive needs.
Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
Establishes a supportive and motivational relationship with patients that support patient self-management
Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
Performs other duties as assigned and modified at manager’s discretion.