Intensive Community Care Manager (RN)

ChenMed • Shively, KY

7d • $37 - $53 • Onsite

About The Position

The Intensive Community Care Manager (ICCM) is a Registered Nurse who provides focused case management and field nursing interventions for the organization’s highest-complexity patients. The role partners with patients, primary care physicians, and other care-team members to prevent unnecessary hospital arrivals, support continued engagement in the intensive primary care model, and maximize patients’ healthy time at home.

Serving as a clinical lead for the Complex Care Team, the ICCM assesses, evaluates, and coordinates efforts to stabilize high-risk patients. Key focus areas include safe transitions from facilities to primary care, stabilization of high-risk ambulatory patients, and outreach to assigned patients who are not engaged in care. The ICCM assesses patients and develops comprehensive care plans, oversees care-plan delivery by other team members, and helps prioritize team efforts. The role may also directly supervise some team members. In partnership with primary care physicians, the ICCM develops personalized care plans addressing immediate risks that could lead to unnecessary hospital arrivals.

The position includes in-house, facility, telephonic, and home visits; clinical and social-needs assessments; care coordination; patient and caregiver education; and follow-up through discharge from case management. The ICCM works within departmental goals, performance standards, regulatory requirements, quality-of-care requirements, and organizational policies and procedures. Local, regional, and nationwide travel of up to 10% is required.

Requirements

• Associate degree in Nursing.
• Valid, active Registered Nurse license in the state of employment.
• At least 2 years of clinical work experience.
• Current, valid driver’s license that must be maintained.
• Basic Life Support certification from the American Heart Association or American Red Cross within the first 90 days of employment.
• Strong interpersonal and communication skills, including the ability to work effectively with diverse constituencies.
• Critical-thinking skills and ability to work autonomously and exercise independent judgment.
• Ability to monitor, assess, and document 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 charts and histories; clinical and social-services documentation procedures and standards; and community health and social-services resources.
• 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, as well as 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 a compact license is available.
• At least 1 year of community case-management experience.
• Certified Case Manager certification, preferably through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN).
• Bilingual ability.

Responsibilities

• Visit high-risk patients in-house, at facilities, by telephone, and in their homes to help prevent unnecessary hospital admissions and readmissions.
• Conduct home visits, perform field nursing interventions, assess patients, and develop care plans identifying goals, barriers, and follow-up interventions.
• Review patient charts and conduct final discharge conversations after completion of a case-management episode; obtain formal Complex Care Leadership Team approval when required.
• Conduct supervisory visits with LPNs and patients to provide additional education and oversee appropriate patient discharge from case management.
• Perform clinical, fall-prevention, and social determinants of health assessments, including disease-oriented assessment and monitoring, medication monitoring, health education, and self-care instruction.
• Perform approved home-based nursing interventions intended to prevent hospital arrivals, such as taking vital signs and weighing patients.
• 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 implement care-plan interventions with patients, caregivers, and care-team members, emphasizing incremental actions to prevent unnecessary hospitalization.
• Assess the care environment for safety and security, conduct fall-risk assessments as needed, and assess caregiver capacity and willingness to provide care.
• Assess and educate patients and caregivers regarding their educational needs.
• Coordinate, report, document, and follow up on multidisciplinary team meetings, serving as host or lead when needed.
• Help patients navigate healthcare systems, connect them with community resources, and coordinate healthcare delivery and related administrative and logistical tasks.
• Coordinate services to address patient needs and coach patients in using natural supports and mainstream community resources.
• Maintain communication with families, community providers, and others to promote patients’ health and well-being.
• Build supportive, motivational relationships that promote 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 home visits under the direction of the patient’s primary care physician to address urgent needs and help prevent unnecessary hospital arrivals.
• Perform other duties as assigned or modified at the manager’s discretion.

Benefits

• Great compensation and comprehensive benefits; specific benefit details are provided through the linked employee benefits resource.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

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