Community Case Manager, RN

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 we need great people to join our team.

About the role

The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) who works with our highest complexity patients, their primary care physicians, and other members of the care team to provide hyperfocus case management and field nursing interventions. The goal is to prevent unnecessary hospital arrivals, keep patients engaged in our intensive primary care model, and maximize their healthy time at home. The ICCM serves as a clinical lead for the Complex Care Team, assessing, evaluating, and coordinating efforts to stabilize our highest-risk patients. Key focus areas include safe transitions of care from facilities back to primary care teams, stabilization of high-risk ambulatory patients, and outreach to unengaged patients. This role involves designing comprehensive care plans, providing clinical supervision, and prioritizing team efforts.

Responsibilities

• Provides in-house, facility, and telephonic visits to high-risk patients to prevent unnecessary hospital admissions and readmissions.
• Conducts home visits to perform field nursing interventions, assess patients, and develop care plans addressing goals, barriers, and follow-up actions.
• Reviews patient charts for discharge and conducts final discharge from the program, with formal approval from Complex Care Leadership when required.
• Performs supervisory visits with Licensed Practical Nurses (LPNs) and patients to provide additional education and oversee appropriate discharge from case management.
• Conducts clinical, fall prevention, and Social Determinants of Health (SDoH) screenings, including disease-oriented assessments, medication monitoring, and health education in outpatient and home settings.
• Performs home field nursing interventions as agreed upon by the PCP, Center Leadership, and Complex Care Leadership to prevent hospital arrivals (e.g., vital signs, patient weighing, one-time visits ordered by PCP).
• Coordinates the plan of care by conducting initial case management assessments, obtaining patient consent, and ensuring care plans reflect patient needs and available community services.
• Completes care plan interventions with patients, families, and care team members, focusing on incremental actions to prevent unnecessary hospitalizations.
• Assesses the environment of care, including safety, security, and fall risk, as well as caregiver capacity and willingness to provide care.
• Educates patients and caregivers on identified needs and coordinates multidisciplinary team meetings as needed.
• Helps patients navigate healthcare systems, connects them with community resources, and orchestrates healthcare delivery.
• Coordinates services to address patient needs, facilitates patient self-management, and maintains ongoing communication with families and providers.
• Monitors the quality, frequency, and appropriateness of home health aide (HHA) visits and other outpatient services.
• Assists patients and families with access to community and financial resources, referring cases to social workers or other programs as appropriate.
• Collaborates with Complex Care and Clinica Strategy Team members, such as Hospital Care Managers and Post Hospital Care Coordinators, to ensure holistic care.
• Performs home visits under the direction of the patient’s primary care physician to address urgent needs and prevent unnecessary hospital arrivals.
• Performs other duties as assigned or modified at the manager’s discretion.

Requirements

• Associate degree in Nursing required; Bachelor’s Degree in Nursing (BSN) or RN with a bachelor’s degree in a related clinical field preferred.
• Valid, active Registered Nurse (RN) license in the state of employment required; Compact License preferred where available.
• Minimum of 2 years’ clinical work experience required.
• Minimum of 1 year of case management experience in community case management highly desired.
• Certified Case Manager certification preferred (e.g., through CCMC or AAMCN).
• Current, valid driver’s license required.
• Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required within the first 90 days of employment.

Skills

• Strong interpersonal and communication skills, with the ability to work effectively with diverse constituencies.
• Critical thinking and ability to work autonomously.
• Ability to monitor, assess, and record patient progress, adjusting plans as needed.
• Knowledge of nursing and case management theory and practice.
• Familiarity with patient care charts, histories, and clinical/social services documentation procedures.
• Knowledge of community health and social services support agencies and networks.
• Organizing and coordinating skills, with the ability to communicate technical information to non-technical personnel.
• Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) and other relevant software.
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
• Spoken and written fluency in English; bilingual skills a plus.

Pay

Pay Range: $36.90 - $52.70 hourly. Final compensation will depend on factors such as experience, education, geographic location, and other relevant considerations. This position may also be eligible for bonuses or commissions.

Benefits

Comprehensive benefits package available. For more details, visit ChenMed’s benefits documentation.