Intensive Community Manager, Complex Care (RN)

ChenMed•Franklin Township, PA

18h•$37 - $53•Hybrid

About The Position

The Intensive Community Manager (ICCM) is a Registered Nurse who provides focused 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, maintain patient engagement in the intensive primary-care model, and maximize healthy time at home. The ICCM serves as a clinical lead for the Complex Care Team, assessing and coordinating efforts to stabilize high-risk patients. Key areas of focus include safe transitions from facilities to primary-care teams, stabilizing high-risk ambulatory patients, and reaching patients who are assigned to the organization but not engaged in care. The role includes patient assessments, comprehensive care planning, oversight and clinical supervision of team members, and prioritization of team efforts. The ICCM partners with primary care physicians on personalized care plans addressing immediate risks. The role may also include direct supervision of some team members. The position is subject to departmental goals and objectives, performance standards, regulatory and quality-of-care requirements, and organizational policies and procedures. It requires local, regional, and nationwide travel of up to 10% of the time.

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, including the ability to work effectively with a wide range of people in a diverse community.
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 charts and histories, and clinical and social-services documentation procedures and standards.
Knowledge of community health services, social-services support agencies, and networks.
Organizing and coordinating skills, and the 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 an 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, such as 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, telephonic, and home visits to high-risk patients to help prevent unnecessary hospital admissions and readmissions.
Conduct home nursing assessments and interventions, develop care plans, and complete patient discharge reviews and discharge conversations after case-management episodes; obtain Complex Care Leadership Team approval when required.
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 assessments, including disease monitoring, medication monitoring, health education, and self-care instruction.
Perform PCP-approved home nursing interventions, such as taking vital signs, weighing patients, and making approved one-time visits, in accordance with standard operating procedures.
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 care-plan interventions with patients, caregivers, and care-team members.
Assess care environments for safety and security, conduct fall-risk assessments as needed, and assess caregiver capacity and willingness to provide care.
Assess and educate patients and caregivers about their 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 with community resources, and manage healthcare delivery, administrative, and logistical tasks.
Coordinate service delivery to address patient needs and facilitate use of natural supports and mainstream community resources.
Maintain communication with families, community providers, and others to promote patient health and well-being; establish supportive 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 and financial resources, and refer cases to social workers or other programs when appropriate.
Collaborate with Complex Care and Clinical Strategy Team members, including Hospital Care Managers and Post Hospital Care Coordinators and Managers, to support holistic patient care.
Make urgent home visits under the direction of the patient’s primary care physician to help prevent unnecessary hospital arrivals.
Provide clinical leadership and supervision to team members, help prioritize team efforts, and potentially directly supervise team members.
Perform other duties as assigned or modified at the manager’s discretion.