Intensive Community Manager, Complex Care (RN)

ChenMed • Louisville, KY

83d

About The Position

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 home health care.
• Strong clinical assessment skills.
• Ability to develop and implement care plans.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively in a multidisciplinary team.

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.
• Conducts supervisory visits with LPN and patient to provide additional education and oversee appropriate patient discharge.
• Performs clinical and Social determination of Health screening assessments.
• Provides oversight for the LPN with clear plan of care and education.
• 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.
• Completes individual plan of cares with patients, family/caregiver and care team members.
• Communicates instructions and methodologies 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 and connects them with community resources.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches patients in using natural supports and mainstream community resources.
• Maintains ongoing communication with families, community providers and others as needed.
• 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 and refers cases to social worker as appropriate.
• Performs home visits under the direction of the patient's primary care physician to meet urgent patient needs.
• Performs other duties as assigned and modified at manager's discretion.

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
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees