Intensive Community Manager, Complex Care 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 patients not currently engaged in care. 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 interventions.
• Reviews patient charts for discharge and conducts final discharge from the program, which may require approval from the Complex Care Leadership Team.
• Performs supervisory visits with Licensed Practical Nurses (LPNs) and patients to provide additional education and oversee appropriate discharge from case management.
• Performs clinical, fall prevention, and social determinants of health (SDoH) screenings, including disease-oriented assessments, medication monitoring, health education, and self-care instructions in outpatient and home settings.
• Delivers home-based 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).
• Conducts and coordinates initial case management assessments to determine outpatient needs and obtain patient consent for the program.
• Ensures individual care plans reflect patient needs and available community services, focusing on incremental actions to prevent unnecessary hospitalizations.
• Assesses the environment of care, including safety, security, and fall risk, as well as the caregiver’s capacity and willingness to provide care.
• Educates patients and caregivers on identified needs and coordinates multidisciplinary team meetings, serving as host or lead as needed.
• Helps patients navigate healthcare systems, connects them with community resources, and assists with administrative and logistical tasks.
• Coordinates service delivery to address patient needs effectively and coaches patients in using natural support and community resources.
• Maintains ongoing communication with families, community providers, and others to promote patient health and well-being.
• Establishes supportive and motivational relationships with patients to encourage self-management.
• 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 closely with other members of the Complex Care and Clinica Strategy Team, 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 and 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 the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN)).
• 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.
• Strong organizing and coordinating skills.
• Ability to communicate technical information to non-technical personnel.
• Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) and other word-processing, spreadsheet, database, email, and presentation software.
• Willingness and ability 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.