Intensive Community Care Manager (RN)

ChenMed•Shively, KY

5d•Onsite

About The Position

The Intensive Community Care Manager (ICCM) is a Registered Nurse who provides intensive case management and field nursing interventions for the organization’s highest-complexity patients. Working with patients, primary care physicians, and other care-team members, the ICCM aims to prevent unnecessary hospital arrivals, support engagement in intensive primary care, and maximize patients’ healthy time at home. The ICCM serves as a clinical lead for the Complex Care Team, coordinating efforts to stabilize high-risk patients, support safe transitions from facilities to primary care, stabilize high-risk ambulatory patients, and reach patients who are not engaged in care. The role includes assessing patients, developing comprehensive care plans, and supervising team members in carrying out care plans and related activities. The ICCM may also prioritize team efforts and directly supervise some team members. The ICCM partners with primary care physicians to develop personalized care plans addressing immediate risks for unnecessary hospital arrivals. The position adheres to departmental objectives, performance standards, regulatory requirements, quality-care standards, and organizational policies and procedures. Work includes in-home, facility-based, and telephone visits; field nursing interventions; patient and caregiver education; care coordination; and discharge from case management when an episode of care is complete. This position requires local, regional, and nationwide travel of up to 10% of the time. The posted base pay range is $36.90–$52.70 per hour. Final compensation depends on factors including experience, education, and geographic location. The position may also be eligible for bonuses or commissions. ChenMed describes its benefits as comprehensive and highlights career development, advancement opportunities, compensation, and work-life balance; specific benefits are not listed in the posting.

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 the ability to work effectively with diverse constituencies.
Critical-thinking skills and the 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; clinical and social-services documentation procedures and standards; and community health and social-services resources and networks.
Organizing and coordinating skills, and ability to communicate technical information to nontechnical 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, including certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN).
Bilingual ability.

Responsibilities

Provide in-house, facility-based, and telephone visits to high-risk patients to help prevent hospital admission and readmission.
Conduct home visits, perform field nursing interventions, assess patients, and develop care plans addressing goals, barriers, and follow-up interventions.
Review patient charts and conduct final discharge from the program when a patient completes an episode of care management; obtain formal approval from the Complex Care Leadership Team when required.
Conduct supervisory visits with LPNs and patients to provide additional 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 in the home setting.
Perform PCP-approved field nursing interventions intended to prevent hospital arrivals, such as taking vital signs and weighing patients, in accordance with applicable approvals and standard operating procedures.
Conduct or coordinate initial case-management assessments, determine outpatient needs, and obtain patient consent to the program.
Develop and maintain individual plans of care that reflect patient needs and available community services or benefits, involving patients, caregivers, families, and care-team members.
Assess the care environment for safety and security, conduct fall-risk assessments as needed, and evaluate caregivers’ capacity and willingness to provide care.
Assess and educate patients and caregivers regarding 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.
Facilitate and coach patients in using natural supports and community resources to address supportive needs.
Maintain communication with families, community providers, and others as needed to promote patient health and well-being.
Establish supportive and 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 or financial resources and refer cases to social workers or other appropriate programs.
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.
Prioritize Complex Care Team efforts and provide clinical supervision to team members; the role may include direct supervision of some team members.
Perform other duties as assigned or modified at the manager’s discretion.