Intensive Community Care Manager, Registered Nurse - Home Health or Home Hospice experience highly preferred!
Intensive Community Care Manager, Registered Nurse - Home Health or Home Hospice experience highly preferred! Apply remote type: Hybrid | locations: West Largo | time type: Full time | posted on: Posted 3 Days Ago | job requisition id: R0041813
We’re unique. You should be, too.
We’re changing lives every day for both our patients and our team members. Are you innovative and entrepreneurial-minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?
We’re different than most primary care providers. We’re rapidly expanding and need great people to join our team.
The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) who works with our highest complexity patients, their primary care physicians, and other care team members. They provide hyperfocused case management and field nursing interventions to prevent unnecessary hospital admissions, keep patients engaged in our primary care model, and maximize their healthy time at home.
The ICCMs serve as clinical leads for the Complex Care Team, assessing, evaluating, and coordinating efforts to stabilize high-risk patients. They focus on safe transitions of care, stabilization of ambulatory patients, and outreach to unengaged patients. They perform assessments, develop care plans, and drive actions to keep patients safely at home. They also provide clinical supervision to team members and may serve as direct supervisors.
This role works closely with PCPs to draft personalized care plans addressing immediate risks and needs.
This position adheres to departmental goals, standards, regulatory compliance, and policies.
Essential Job Duties/Responsibilities: Provide in-house, facility, and telephonic visits to high-risk patients to prevent hospital admissions.
Perform home visits, assess patients, develop care plans, and discharge patients after completing their care episode.
Conduct supervisory visits with LPNs and patients for education and discharge oversight.
Perform clinical assessments including fall prevention, social determinants of health, and disease monitoring.
Coordinate the Plan of Care: conduct assessments, ensure plans reflect patient needs, and facilitate multidisciplinary team meetings.
Assist patients in navigating healthcare systems and accessing community resources.
Maintain ongoing communication with families and providers to promote patient well-being.
Establish supportive relationships to promote self-management.
Monitor quality and appropriateness of outpatient visits and services.
Assist with access to community/financial resources and refer to social workers as needed.
Collaborate with team members to ensure holistic care.
Perform home visits under physician direction to prevent hospitalizations.
Perform other duties as assigned.
Knowledge, Skills, and Abilities: Strong interpersonal and communication skills.
Critical thinking and autonomous working ability.
Assessment and care planning skills.
Knowledge of nursing, case management, and community health services.
Organizational and coordination skills.
Proficiency in Microsoft Office and other software.
Willingness to travel up to 10%.
Fluency in English; bilingual preferred.
Independent judgment required.
Education and Experience: Associate degree in Nursing required.
Bachelor’s Degree preferred.
Active RN license required; compact license preferred.
Minimum 2 years clinical experience; 1 year community case management preferred.
Case management certification preferred.
Valid driver’s license required.
We’re ChenMed, transforming healthcare for seniors. Join us to make a difference. Great benefits, career growth, and a supportive environment await.
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About Us ChenMed is a family-owned, physician-led organization dedicated to healthcare for low-to-moderate income seniors. Our vision is to positively change American healthcare through primary care innovation. Our mission is to provide patient-centered, coordinated care that fosters enduring relationships and delivers superior outcomes. We promise to prioritize your health and well-being, treating you like family.