RN Case Manager

ChenMed•West Philadelphia, NC

22h•Hybrid

About The Position

We are a unique, rapidly expanding primary care provider that is transforming healthcare for seniors. We are seeking innovative and ambitious individuals to join our team. This on-site role requires working Monday through Friday, with hours between 7:30 am and 5:00 pm. The position involves both on-site work at our healthcare offices and in-home patient visits, supporting patients from our West Philadelphia and North Philadelphia locations. The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) responsible for hyperfocus case management and field nursing interventions for our highest complexity patients. The primary goals are to prevent unnecessary hospitalizations, keep patients engaged in our intensive primary care model, and maximize their healthy time at home. The ICCM will serve as a clinical lead for the Complex Care Team, assessing, evaluating, and coordinating efforts to stabilize high-risk patients. Key focus areas include safe transitions of care from facilities, stabilization of high-risk ambulatory patients, and outreach to unengaged patients. This role involves performing assessments, designing comprehensive care plans, and driving actions to ensure patients remain safely at home. The ICCM will also provide clinical supervision to other team members and may become a direct supervisor for some. This position works in partnership with Primary Care Physicians (PCPs) to draft personalized care plans addressing immediate risks and adheres to strict departmental goals, regulatory compliance, and quality patient care standards.

Requirements

Associate degree in Nursing required
A valid, active Registered Nurse (RN) license in State of employment required.
A minimum of 2 years’ clinical work experience required
This position requires possession and maintenance of a current, valid driver’s license.
Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment

Nice To Haves

Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in home in a related clinical field preferred
Compact License preferred for states where compact license is available
A minimum of 1 year of case management experience in community case management experience highly desired
Certified Case Manager certification is preferred.
Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired
Bilingual a plus

Responsibilities

Provides in-house, at facility, and telephonic visits to patients at high-risk for hospital admission and re-admission with the main goal of preventing unnecessary hospital arrivals for patients that have consented to the program and after successfully completed full course of program.
Provides home visits to perform field nursing interventions, assess patient, and the development of care plan to identify the goals, barriers, and interventions that will be addressing during the follow up patient visits.
Reviews patient chart for discharge and conducts final discharge with patient once they have completed their episode of care management. Discharge from program may require formal approval from Complex Care Leadership Team.
Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
Performs clinical, fall prevention, and social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
Performs home field nursing interventions that have been agreed by PCP, Center Leadership, and Complex Care Leadership that would prevent hospital arrival. Such intervention may include taking vital signs, weighing patient, appropriate one time visits ordered by PCP and reviewed by the Manager for approval, and others as determined in Standard Operation Procedures (SOPs).
Conducts/coordinates initial case management assessment of patients to determine outpatient needs and obtains patients consent to program.
Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
Completes individual plan of care intervention with patients, family/caregiver and care team members with a focus of incremental actions that will prevent unnecessary hospitalizations.
Assesses the environment of care, e.g., safety and security. Conduct fall risk assessment as needed.
Assesses the caregiver’s capacity and willingness to provide care.
Assesses and educates patient and caregiver educational needs.
Coordinates, reports, documents and follows-up on multidisciplinary team meetings serving as host or lead for those conversations as needed.
Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
Coordinates the delivery of services to effectively address patient needs.
Facilitates and coaches patients in using natural support and mainstream community resources to address supportive needs.
Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
Establishes a supportive and motivational relationship with patients that support patient self-management.
Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Assists patients and family with access to community/financial resources and refer cases to social worker and other programs available as appropriate.
Collaborates closely with other members of the Complex Care and Clinical Strategy Team such as Hospital Care Managers and Post Hospital Care Coordinators and Managers to ensure patients in their program receive holistic care approval.
Home visit under the direction of the patient’s primary care physician to meet urgent patient needed with the aim of preventing unnecessary hospital arrivals.
Performs other duties as assigned and modified at manager’s discretion.