Intensive Community Manager, Complex Care (RN)

ChenMed • Town "n" Country, FL

1d • $37 - $53

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. The role partners with patients, primary care physicians, and other care-team members to prevent unnecessary hospital arrivals, support patient engagement in the intensive primary care model, and maximize patients’ healthy time at home.

Serving as a clinical lead for the Complex Care Team, the manager assesses and coordinates care for high-risk patients, including 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 develops comprehensive, individualized care plans, oversees interventions, and provides clinical supervision to team members. It may also include direct supervision of some team members. The position works with PCPs to develop personalized care plans addressing immediate risks that could lead to unnecessary hospital arrivals, and follows departmental objectives, performance standards, regulatory requirements, quality standards, 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 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-services 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, 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, and telephonic visits to high-risk patients to help prevent hospital admission and readmission.
• 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-based nursing interventions, such as taking vital signs, weighing patients, and completing appropriate PCP-ordered visits in accordance with operating procedures.
• Coordinate initial case-management assessments, determine outpatient needs, and obtain patient consent to the program.
• Ensure individual care plans reflect patient needs and available community services or benefits.
• Develop and implement care-plan interventions with patients, caregivers, and care-team members, focusing on incremental actions to prevent unnecessary hospitalizations.
• Assess the care environment for safety and security, conduct fall-risk assessments as needed, and evaluate 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; host or lead discussions as needed.
• Help patients navigate healthcare systems, connect with community resources, coordinate healthcare delivery, and assist with administrative and logistical tasks.
• Coordinate services to address patient needs and coach patients in using natural supports and mainstream 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 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.
• Perform other duties as assigned or modified at the manager’s discretion.

Benefits

• The posting refers to comprehensive employee benefits but does not specify individual benefit offerings.
• Compensation may include bonuses or commissions.
• Career development and advancement opportunities.
• Work-life balance.

What This Job Offers

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