Intensive Community Manager, Complex Care (RN)

ChenMed•Louisville, KY

28d•Hybrid

About The Position

We are seeking an innovative and entrepreneurial-minded Intensive Community Manager, Complex Care (RN) to join our rapidly expanding team. This role is part of the Community Care team, 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). This team works with our highest complexity patients and their primary care physicians to meet their medical and social needs, aiming to fully engage them in our intensive primary care model and maximize their healthy time at home. The RN Community Care Nurse will serve as a clinical lead, coordinating efforts to stabilize high-risk patients, focusing on safe transitions of care from facilities, stabilization of high-risk ambulatory patients, and outreach to unengaged patients. This role involves performing initial assessments, designing comprehensive care plans, providing clinical supervision to team members, prioritizing team efforts, and potentially direct supervision of some team members. The position adheres to strict departmental goals, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

Requirements

Registered Nurse (RN)
Clinical lead for a Community Care team
Coordinate team's efforts to stabilize highest risk patients
Focus on safe transitions of care from facilities back to primary care teams
Stabilization of highest risk ambulatory patients
Outreach to patients not engaged in care
Perform initial assessments
Design comprehensive plans of care
Provide clinical supervision to other team members
Prioritize team efforts
May become direct supervisor for some team members
Adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures

Nice To Haves

Innovative and entrepreneurial minded
High work ethic and ambition
Inspires others with kindness and joy

Responsibilities

Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital.
Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
Completes individual plan of cares with patients, family/care giver and care team members.
Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
Assesses the environment of care, e.g., safety and security.
Assesses the caregiver capacity and willingness to provide care.
Assesses patient and caregiver educational needs.
Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
Coordinates the delivery of services to effectively address patient needs.
Facilitates and coaches’ patients in using natural supports and mainstream community resources to address supportive needs.
Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
Establishes a supportive and motivational relationship with patients that support patient self-management.
Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
Performs other duties as assigned and modified at manager’s discretion.