Intensive Community Care Manager , Registered Nurse - Home Health or Home Hospice experience highly preferred!

ChenMed • Largo, FL

94d • Hybrid

About The Position

The Community Care team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home. The Register Nurse (RN) Community Care Nurse will serve as a clinical lead for a Community Care team. They will 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 initial assessments and design comprehensive plans of care for many of these patients. 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. This position adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

Requirements

• Associate degree in Nursing required.
• A valid, active Registered Nurse (RN) license in State of employment required.
• A minimum of 2 years' clinical work experience required.
• A minimum of 1 year of case management experience in community case management experience highly desired.
• This position requires possession and maintenance of a current, valid driver's license.
• Strong interpersonal and communication skills.
• Critical thinking skills required.
• Ability to work autonomously.
• Ability to monitor, assess and record patients' progress.
• Knowledge of nursing and case management theory and practice.
• Knowledge of patient care charts and patient histories.
• Knowledge of clinical and social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies.
• Proficient in Microsoft Office Suite products.
• Spoken and written fluency in English.

Nice To Haves

• Bachelor's Degree in nursing (BSN) or RN with bachelor's degree in a related clinical field preferred.
• Certified Case Manager certification is preferred.
• Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.
• Bilingual a plus.

Responsibilities

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission.
• Conducts initial assessment of patient and develops care plan for the Licensed Practical Nurse (LPN) to use.
• Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide additional education.
• Performs clinical and Social determination of Health screening assessments.
• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Completes individual plan of cares with patients, family/caregiver and care team members.
• Communicates instructions and methodologies 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 and connects them with community resources.
• Facilitates and coaches patients in using natural supports and mainstream community resources.
• Maintains ongoing communication with families, community providers and others.
• Establishes a supportive and motivational relationship with patients.
• Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial resources.
• Performs home visits under the direction of the patient's primary care physician.
• Performs other duties as assigned.

Benefits

• Great compensation.
• Comprehensive benefits.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees