Intensive Community Manager, Complex Care (RN)

ChenMed • Shively, KY

92d

About The Position

The Community Care team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home. The Register Nurse (RN) Community Care Nurse will serve as a clinical lead for a Community Care team. They will coordinate the team’s efforts to stabilize our highest risk patients, with special areas of focus including safe transitions of care from facilities back to our primary care teams, stabilization of our highest risk ambulatory patients and outreach to patients who are assigned to us but are not engaged in care. This person will perform initial assessments and design comprehensive plans of care for many of these patients. This professional will also provide clinical supervision to other team members in delivering the plan of care and in other tasks necessary to meet their needs and engage them in care. As a clinical leader for the team, this person will also be deeply involved in prioritizing team efforts and may also become the direct supervisor for some team members. This position adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

Requirements

• Registered Nurse (RN) license.
• Experience in community health or primary care.
• Strong clinical assessment skills.
• Ability to work collaboratively in a multidisciplinary team.
• Excellent communication and interpersonal skills.

Nice To Haves

• Experience with high-risk patient populations.
• Knowledge of community resources and healthcare systems.
• Leadership experience in a clinical setting.

Responsibilities

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission.
• Conducts initial assessment of patient and develops care plan for the Licensed Practical Nurse (LPN) to use.
• Reviews patient chart for discharge and conducts final discharge with patient.
• Conducts supervisory visits with LPN and patient to provide additional education and oversee appropriate patient discharge.
• Performs clinical and Social Determination of Health (SdoH) assessments.
• Coordinates the Plan of Care and provides oversight for the LPN.
• Completes individual plan of cares with patients, family/caregiver and care team members.
• Communicates instructions and methodologies to ensure the plan is implemented correctly.
• Assesses the environment of care, caregiver capacity, and patient educational needs.
• Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
• Helps patients navigate health care systems and connects them with community resources.
• Maintains ongoing communication with families, community providers and others.
• Establishes a supportive and motivational relationship with patients.
• Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial resources.
• Performs other duties as assigned.

Benefits

• Great compensation.
• Comprehensive benefits.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees