Intensive Community Care Manager (RN)

ChenMed • Louisville, KY

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 high-complexity patients in collaboration with primary care physicians and other care-team members. The role focuses on preventing unnecessary hospital arrivals, supporting patient engagement in the intensive primary care model, and maximizing patients’ healthy time at home.

The ICCM serves as a clinical lead for the Complex Care Team, assessing and coordinating efforts to stabilize high-risk patients. Focus areas include safe transitions from facilities back to primary care, stabilization of high-risk ambulatory patients, and outreach to patients who are assigned to the organization but not engaged in care. The role develops comprehensive care plans, supervises clinical delivery by other team members, helps prioritize team efforts, and may directly supervise some team members. The ICCM partners with primary care physicians to develop personalized plans addressing immediate risks that could lead to unnecessary hospital arrivals.

The position follows departmental objectives, performance standards, regulatory requirements, quality-of-care requirements, and organizational policies and procedures. It includes in-house, facility, telephonic, and home visits, as well as coordination with patients, caregivers, families, community providers, and multidisciplinary teams. Local, regional, and nationwide travel of up to 10% is required.

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, including the ability to work effectively with a wide range of people in a diverse community.
• 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-care charts and histories, and clinical and social-services documentation procedures and standards.
• Knowledge of community health services and social-services support agencies and networks.
• Organizing and coordinating skills, and ability to explain 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.
• Spoken and written fluency in English.

Nice To Haves

• Bachelor’s degree in Nursing (BSN), or an RN with a bachelor’s degree in a related clinical field.
• At least 1 year of community case-management experience.
• Compact RN license in states where available.
• 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 help prevent unnecessary hospital arrivals and readmissions.
• Perform field nursing interventions, assess patients, and develop care plans identifying goals, barriers, and follow-up interventions.
• Review patient charts and conduct final discharge discussions when a patient completes an episode of care management; obtain formal Complex Care Leadership Team 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 assessments, including disease-oriented assessment and monitoring, medication monitoring, health education, and self-care instruction.
• Perform home nursing interventions agreed upon by the PCP and relevant leadership, such as taking vital signs, weighing patients, and completing approved one-time visits.
• Conduct or coordinate initial case-management assessments and obtain patient consent for the program.
• Ensure individual care plans reflect patient needs and available community services or benefits.
• Work with patients, families or caregivers, and care-team members on incremental care-plan actions intended to prevent unnecessary hospitalizations.
• Assess the care environment, safety and security, fall risk, caregiver capacity and willingness, and patient and caregiver education needs.
• Coordinate, report, document, and follow up on multidisciplinary team meetings, serving as host or lead when needed.
• Help patients navigate healthcare systems, connect with community resources, and manage administrative and logistical aspects of care delivery.
• 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 patient health and well-being.
• Build supportive and motivational relationships that encourage patient self-management.
• Monitor the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Help patients and families access community and financial resources, referring cases to social workers and 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 or modified at the manager’s discretion.

Benefits

• The posting describes comprehensive benefits, but does not specify individual benefit types.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

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