Intensive Community Manager, Complex Care (RN)

ChenMed • Olney, MD

9d • Onsite

About The Position

The Intensive Community Manager (ICCM) is a Registered Nurse who provides intensive case management and field nursing interventions for patients with the highest levels of complexity. The role partners with primary care physicians and the broader care team to prevent unnecessary hospital arrivals, support patient engagement in intensive primary care, and maximize patients’ healthy time at home. The ICCM serves as a clinical lead for the Complex Care Team, coordinating efforts to stabilize high-risk patients, support safe transitions from facilities to primary care, stabilize high-risk ambulatory patients, and reach patients who are not engaged in care.

The position is on-site, supports two Philadelphia locations (Olney and Mayfair), and requires daily in-home patient visits. The schedule is Monday through Friday, 7:30 a.m.–4:30 p.m. or 8:00 a.m.–5:00 p.m. The ICCM assesses patients and their environments, develops personalized plans of care with PCPs, coordinates services and community resources, and provides clinical supervision to team members delivering care. The role may also directly supervise some team members and helps prioritize team efforts. It requires adherence to departmental goals, performance standards, regulatory requirements, quality-of-care requirements, and 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, including the ability to work effectively with diverse constituencies.
• Critical-thinking skills and the ability to work autonomously.
• 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; clinical and social services documentation procedures and standards; and community health and social services 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.
• Ability to use and exercise independent judgment.

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, including 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-based, telephonic, and home visits to high-risk patients to help prevent unnecessary hospital arrivals and readmissions.
• Perform home nursing interventions and patient assessments, and develop care plans identifying goals, barriers, and follow-up interventions.
• Review patient charts and conduct final discharge from case management when patients complete their episode of care; obtain Complex Care Leadership Team approval when required.
• Conduct supervisory visits with LPNs and patients to provide education and oversee appropriate patient 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.
• Provide home-based nursing interventions agreed upon by the PCP and relevant leadership, such as taking vital signs, weighing patients, and approved one-time visits.
• Conduct or coordinate initial case management assessments and obtain patient consent to the program.
• Create and update individualized plans of care that reflect patient needs and available community services or benefits, involving patients, caregivers, families, and the care team.
• Assess the care environment, including safety and security; conduct fall-risk assessments; assess caregiver capacity and willingness; and identify 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 coordinate the administrative and logistical aspects of care delivery.
• Coach patients in using natural supports and mainstream community resources to address supportive needs.
• Maintain communication with families, community providers, and others as needed to promote patient health and well-being.
• Build supportive, motivational 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 appropriate programs.
• 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 home visits under the direction of the patient’s PCP to address urgent needs and help prevent unnecessary hospital arrivals.
• Provide clinical supervision to team members and contribute to prioritizing team efforts; may directly supervise some team members.
• Perform other duties as assigned or modified by the manager.

Benefits

• The posting states that employees receive comprehensive benefits, but does not specify individual benefit types.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

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