Intensive Community Care Manager (RN)

ChenMed • Columbus, OH

6d • $37 - $53 • Onsite

About The Position

The Intensive Community Care Manager (ICCM) is a Registered Nurse who provides intensive case management and field nursing interventions for patients with the highest complexity and risk. The role partners with patients’ primary care physicians and the broader care team to prevent unnecessary hospital arrivals, keep patients engaged in intensive primary care, and maximize healthy time at home.

As a clinical lead for the Complex Care Team, the ICCM assesses and coordinates efforts to stabilize high-risk patients, including transitions from facilities to primary care, stabilization of high-risk ambulatory patients, and outreach to patients who are not engaged in care. The role develops comprehensive, personalized care plans and oversees care-team actions to help patients remain safely at home. It provides clinical supervision to team members and may directly supervise some team members. The role works in partnership with primary care physicians and must adhere to departmental objectives, performance standards, regulatory requirements, quality standards, and policies and procedures.

Requirements

• Associate degree in Nursing.
• Valid, active Registered Nurse (RN) license in the state of employment.
• At least 2 years of clinical work experience.
• Current, valid driver’s license, which must be maintained.
• Basic Life Support (BLS) certification from the American Heart Association or American Red Cross within the first 90 days of employment.
• Strong interpersonal and communication skills and ability to work effectively with diverse constituencies.
• Critical-thinking skills and ability to work autonomously and exercise independent judgment.
• Ability to monitor, assess, and record patient progress and adjust plans accordingly.
• Ability to plan, implement, and evaluate individual patient care plans.
• Knowledge of nursing and case-management theory and practice; patient care charts and histories; clinical and social-services documentation procedures and standards; and community health and social-services resources and networks.
• Organizational and coordination skills, and ability to communicate technical information to non-technical personnel.
• Proficiency with Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook, and other word-processing, spreadsheet, database, email, and presentation software.
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
• Fluency in spoken and written English.

Nice To Haves

• Bachelor’s degree in Nursing (BSN), or RN with a bachelor’s degree in a related clinical field.
• Compact RN license in states where available.
• At least 1 year of community case-management experience.
• Certified Case Manager certification through the Commission for Case Manager Certification (CCMC) or certification through the American Association of Managed Care Nurses (CMCN).
• Bilingual ability.

Responsibilities

• Provide in-house, facility, telephonic, and home visits to high-risk patients to prevent unnecessary hospital admissions and readmissions.
• Perform home nursing interventions, assess patients, develop care plans, identify goals and barriers, and conduct follow-up visits.
• Review patient charts and conduct final patient discharges from case management; obtain leadership approval when required.
• Conduct supervisory visits with LPNs and patients to provide education and oversee appropriate discharge from case management.
• Perform clinical, fall-prevention, and social determinants of health screenings, including disease assessment and monitoring, medication monitoring, health education, and self-care instruction.
• Perform approved home nursing interventions, such as taking vital signs, weighing patients, and completing one-time visits ordered by a PCP and approved by a manager.
• Conduct or coordinate initial case-management assessments and obtain patient consent to the program.
• Ensure individual care plans reflect patient needs and available community services or benefits.
• Develop and carry out care-plan interventions with patients, caregivers, families, and care-team members, focusing on actions that prevent unnecessary hospitalizations.
• Assess the safety and security of the care environment, caregiver capacity and willingness, and patient and caregiver education needs; conduct fall-risk assessments as needed.
• Coordinate, document, report on, and follow up after multidisciplinary team meetings, serving as host or lead when needed.
• Help patients navigate health care systems and connect with community resources; coordinate health care delivery and assist with administrative and logistical tasks.
• Coordinate services to address patient needs and coach patients in using natural supports and community resources.
• Maintain communication with families, community providers, and others to promote patient health and well-being.
• Build supportive, motivational relationships that encourage patient self-management.
• Monitor the quality, frequency, and appropriateness of home health aide visits and other outpatient services.
• Help patients and families access community and financial resources and refer cases to social workers or other programs as appropriate.
• Collaborate with Complex Care and Clinical Strategy Team members, including Hospital Care Managers and Post Hospital Care Coordinators and Managers, to support holistic care.
• Conduct urgent home visits under the direction of the patient’s primary care physician to help prevent unnecessary hospital arrivals.
• Perform other duties as assigned and modified at the manager’s discretion.

Benefits

• The posting refers to comprehensive employee benefits and links to a benefits resource, but does not specify individual benefits.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree