Intensive Community Manager, Complex Care (RN)

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. The ICCMs provide hyperfocus case management and field nursing interventions to prevent unnecessary hospital arrivals, keep patients engaged in our intensive primary care model, and maximize their healthy time at home.

Responsibilities

• Provides in-house, at facility, and telephonic visits to patients at high-risk for hospital admission and re-admission (as identified by CM Plan) 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.
• Performs home visits to perform field nursing interventions, assess patient, and develop care plan to identify 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. Discharge from program may require formal approval from Complex Care Leadership Team.
• Supervises visits with LPNs and patients to provide additional education and oversee appropriate patient discharge from case management.
• Performs clinical, fall prevention, and social determinants of health (SDoH) assessments, including disease-oriented assessments, medication monitoring, health education, and self-care instructions in the outpatient in-home setting.
• Performs home field nursing interventions that have been agreed upon by PCP, Center Leadership, and Complex Care Leadership, which 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).
• Coordinates the plan of care, conducting initial case management assessments of patients to determine outpatient needs and obtaining patients' consent to the program.
• Completes individual plan of care interventions with patients, family/caregiver, and care team members with a focus on incremental actions that will prevent unnecessary hospitalizations.
• Affirms the environment of care, e.g., safety and security. Conducts fall risk assessments as needed. Assesses 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, connects them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• 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 supports 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 refers cases to social worker and other programs available 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 and manages to ensure patients in their program receive holistic care approval.
• Performs other duties as assigned and modified at manager's discretion.

Qualifications

• Associate degree in Nursing required.
• Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in home in a related clinical field preferred.
• A valid, active Registered Nurse (RN) license in State of employment required. Compact License preferred for states where compact license is available.
• A minimum of 2 years’ clinical work experience required.
• 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.

Skills and Abilities

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking skills.
• Ability to work autonomously.
• Ability to monitor, assess, and record patients’ progress and adjust and plan accordingly.
• Knowledge of nursing and case management theory and practice.
• Knowledge of patient care charts and patient histories.
• Knowledge of clinical and social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies and networks.
• Organizing and coordinating skills.
• Ability to communicate technical information to non-technical personnel.
• Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
• Spoken and written fluency in English. Bilingual a plus.

Pay and Benefits

This position is eligible for a range of pay based on experience, education, and other relevant factors. Employee benefits include a comprehensive package that includes health insurance, retirement plans, paid time off, and more. Join our team who make a difference in people’s lives every single day.

For current employees interested in applying to our internal career site, please click HERE. For current contingent workers interested in applying, please see the job aid HERE.