Intensive Community Care Manager (RN)

ChenMed•Prairie Township, OH

7d•$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 levels of complexity. The role works with patients, primary care physicians, and other care-team members to prevent unnecessary hospital arrivals, maintain patient engagement in intensive primary care, 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 performs assessments, develops comprehensive and personalized care plans, and oversees actions to help complex patients remain safely at home. The role provides clinical supervision to team members and helps prioritize team efforts; it may also directly supervise some team members. The ICCM partners with primary care physicians to develop care plans addressing immediate risks for unnecessary hospital arrivals. The position is subject to departmental goals and objectives, performance standards, regulatory and quality-of-care compliance requirements, and organizational policies and procedures. Local, regional, and nationwide travel of up to 10% is required. The position requires a current, valid driver’s license.

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 using 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-service agencies and networks.
Organizing and coordinating skills, and ability to communicate technical information to non-technical personnel.
Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook, and other word-processing, spreadsheet, database, email, and presentation software.
Willingness and ability 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, such as CCMC or CMCN.
Bilingual ability.

Responsibilities

Provide in-house, facility-based, telephonic, and home visits to high-risk patients to help prevent unnecessary hospital admissions and readmissions.
Perform home nursing interventions, assess patients, and develop care plans identifying goals, barriers, and follow-up interventions.
Review patient charts and conduct final patient discharge from the care-management program; 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 monitoring, medication monitoring, health education, and self-care instruction.
Perform PCP-approved home nursing interventions intended to prevent hospital arrivals, consistent with applicable approvals and standard operating procedures.
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, families or 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 caregivers’ 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 community resources.
Maintain communication with families, community providers, and others to promote patient health and well-being.
Establish 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 them 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 patient care.
Conduct urgent home visits under the direction of the patient’s primary care physician to help prevent unnecessary hospital arrivals.
Provide clinical supervision to team members, help prioritize team efforts, and potentially directly supervise some team members.
Perform other duties as assigned or modified at the manager’s discretion.