Intensive Community Manager, Complex Care (RN)

ChenMed•Portsmouth, VA

10d•$37 - $53•Onsite

About The Position

The Intensive Community Care Manager (ICCM) is a Registered Nurse who provides intensive 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, keep patients engaged 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 focus areas include transitions from facilities back to primary care, stabilization of high-risk ambulatory patients, and outreach to patients who are not engaged in care. The role includes assessing patients, developing comprehensive care plans, directing interventions, providing clinical supervision to team members, and helping prioritize team efforts. The ICCM partners with primary care physicians to create personalized plans addressing immediate risks. The role may also include direct supervision of some team members. This position is on-site at the Portsmouth location and requires daily in-home 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. Local, regional, and nationwide travel of up to 10% is required. The role follows departmental objectives, performance standards, regulatory and quality requirements, and organizational policies and procedures.

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 and 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, and clinical and social services documentation standards.
Knowledge of community health services, social services support agencies, and networks.
Organizing and coordinating skills, including 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 RN with a bachelor’s degree in a related clinical field.
Compact RN license in states where a compact license is available.
At least 1 year of community case management experience.
Certified Case Manager certification, preferably 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 for high-risk patients to help prevent hospital admissions and readmissions.
Conduct home visits, perform field nursing interventions, assess patients, and develop care plans identifying goals, barriers, and follow-up interventions.
Review patient charts and conduct final discharge from case management after an episode of care; obtain formal 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 approved home nursing interventions, such as taking vital signs, weighing patients, and making approved one-time visits ordered by a PCP.
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.
Develop and carry out care-plan interventions with patients, caregivers, families, and care-team members, emphasizing incremental actions to prevent unnecessary hospitalization.
Assess the safety and security of the care environment, conduct fall-risk assessments as needed, and assess caregivers’ capacity and willingness to provide care.
Assess and educate patients and caregivers regarding educational needs.
Coordinate, report, document, and follow up on multidisciplinary team meetings, serving as host or lead when needed.
Help patients navigate health care systems, connect them with community resources, and coordinate health care delivery and related administrative and logistical tasks.
Coordinate services to address patient needs and coach patients in using natural supports and community resources.
Maintain communication with families, community providers, and others to promote patient health and well-being.
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 and financial resources and refer cases 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.