Intensive Community Manager, Complex Care (RN)

ChenMed • Philadelphia, PA

5d • $37 - $53 • Onsite

About The Position

The Intensive Community Manager, Complex Care (RN), is a Registered Nurse who works with high-complexity patients, primary care physicians, and care teams to provide intensive case management and field nursing interventions. The role aims to prevent unnecessary hospital arrivals, keep patients engaged in the intensive primary care model, and maximize healthy time at home. The position is on-site, supports two Philadelphia locations (Olney and Mayfair), and requires daily in-home patient visits. Hours are Monday through Friday, either 7:30 a.m.–4:30 p.m. or 8:00 a.m.–5:00 p.m.

The Intensive Community Manager serves as a clinical lead for the Complex Care Team, assessing and coordinating efforts to stabilize high-risk patients. Focus areas include safe transitions from facilities to primary care, stabilization of high-risk ambulatory patients, and outreach to patients who are not engaged in care. The role performs assessments, develops comprehensive care plans, and directs actions intended to keep complex patients safely at home. It provides clinical supervision to team members and may directly supervise some team members. The manager partners with primary care physicians to develop personalized care plans and adheres to departmental objectives, performance standards, regulatory requirements, quality standards, and 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 and ability to work effectively with diverse constituencies.
• Critical-thinking skills and ability to work autonomously and exercise independent judgment.
• Ability to monitor, assess, and record 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; clinical and social-services documentation; and community health and social-services resources.
• Organizing and coordinating skills, including 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 available.
• At least 1 year of community case-management experience.
• Certified Case Manager certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN).
• Bilingual ability.

Responsibilities

• Provide in-house, facility, telephone, and home visits to high-risk patients to help prevent unnecessary hospital arrivals and readmissions.
• Conduct field nursing interventions and patient assessments; develop care plans identifying goals, barriers, and follow-up interventions.
• Review patient charts and conduct final patient discharges after completion of case management episodes; obtain leadership approval when required.
• Conduct supervisory visits with LPNs and patients to provide education and oversee appropriate case-management discharge.
• 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 PCP-ordered visits in accordance with procedures.
• Conduct or coordinate initial case-management assessments and obtain patient consent to participate in the program.
• Ensure individual care plans reflect patient needs and available community services or benefits, and complete care-plan interventions with patients, caregivers, and care-team members.
• Assess home safety, fall risk, caregiver capacity and willingness, and patient and caregiver education needs.
• Coordinate, document, report, and follow up on multidisciplinary team meetings, serving as host or lead when needed.
• Help patients navigate health-care systems and connect them with community resources; coordinate health-care 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 and financial resources and refer them to social workers or other programs as appropriate.
• Collaborate with Complex Care and Clinical Strategy Team colleagues, including hospital care managers and post-hospital care coordinators, to support holistic care.
• Make urgent home visits under the direction of the patient’s primary care physician to help prevent unnecessary hospital arrivals.
• Provide clinical supervision to team members and contribute to prioritizing team efforts; may directly supervise team members.
• Perform other duties as assigned or modified at the manager’s discretion.

Benefits

• Great compensation and comprehensive benefits are mentioned; specific benefits are linked on the company benefits page.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

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