Intensive Community Manager, Complex Care (RN)

ChenMed • Olney, MD

11d • $37 - $53 • Onsite

About The Position

The Intensive Community Care Manager (ICCM) is a Registered Nurse who provides focused case management and field nursing interventions for patients with the highest levels of complexity. 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 help patients remain safely at home. The role is the clinical lead for the Complex Care Team, assessing and coordinating care for high-risk patients, including transitions from facilities, stabilization of high-risk ambulatory patients, and outreach to people who are not engaged in care. The ICCM develops comprehensive, individualized care plans and provides clinical supervision to team members delivering those plans; the role may also directly supervise some team members. The ICCM partners with primary care physicians to address patients’ immediate needs and risks.

This is an on-site position supporting two Philadelphia locations (Olney and Mayfair) and requires daily in-home patient visits. The stated schedule is Monday through Friday, either 7:30 a.m.–4:30 p.m. or 8:00 a.m.–5:00 p.m. The role adheres to departmental goals, performance standards, regulatory and quality requirements, and organizational policies and procedures.

Requirements

• Associate degree in Nursing.
• Valid, active Registered Nurse 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 certification from the American Heart Association or American Red Cross within the first 90 days of employment.
• Strong interpersonal and communication skills, including the ability to work effectively with diverse constituencies.
• Critical-thinking skills and ability to work autonomously using 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-service agencies and networks.
• Organizing and coordinating skills, and ability to communicate technical information to non-technical 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, where available.
• At least 1 year of community case-management experience.
• Certified Case Manager certification through the Commission for Case Manager Certification (CCMC) or certification through the American Association of Managed Care Nurses (CMCN).
• Bilingual ability.

Responsibilities

• Provide in-house, facility, telephonic, and home visits to high-risk patients to help prevent unnecessary hospital admissions and readmissions.
• Conduct home-based nursing assessments and interventions, develop care plans identifying goals, barriers, and follow-up interventions, and complete patient discharge from the program when appropriate.
• 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 screenings, disease-oriented assessment and monitoring, medication monitoring, health education, and self-care instruction in the outpatient home setting.
• Perform home nursing interventions approved by the PCP and relevant leadership, such as taking vital signs, weighing patients, and conducting approved one-time visits.
• 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, and carry out plan interventions with patients, caregivers, and care-team members.
• Assess the care environment, safety and security, fall risk, caregiver capacity and willingness, and patient and caregiver education needs.
• Coordinate, document, report on, and follow up after multidisciplinary team meetings, serving as host or lead when needed.
• Help patients navigate healthcare systems, connect with community resources, and manage healthcare delivery and related administrative and logistical tasks.
• Coordinate services, coach patients in using natural supports and community resources, and maintain communication with families and community providers.
• Build 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 or 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 care.
• Conduct urgent home visits under the direction of the patient’s PCP to help prevent unnecessary hospital arrivals.
• Perform other duties as assigned or modified at the manager’s discretion.

Benefits

• Great compensation and comprehensive benefits are mentioned; specific benefit offerings are linked externally and are not listed in the posting.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree