ChenMed is seeking an Intensive Community Care Manager (RN) to serve as a clinical lead for the Complex Care Team. The RN will work with high-risk patients, their primary care physicians, and a multidisciplinary care team to provide hyperfocus case management and field nursing interventions aimed at preventing unnecessary hospital admissions and keeping patients engaged in care at home. The Intensive Community Care Manager will assess, evaluate, and coordinate the team’s efforts to stabilize the most complex patients, with emphasis on safe transitions of care from facilities to primary care, outreach to patients who are not engaged in care, and development of comprehensive care plans. This role includes clinical supervision of team members and, for some positions, direct supervision of staff. The clinician will collaborate with PCPs to tailor plans of care to patient needs. This position adheres to departmental goals, standards of performance, regulatory compliance, and quality patient care protocols.
ChenMed is seeking an Intensive Community Care Manager (RN) to serve as a clinical lead for the Complex Care Team. The RN will work with high-risk patients, their primary care physicians, and a multidisciplinary care team to provide hyperfocus case management and field nursing interventions aimed at preventing unnecessary hospital admissions and keeping patients engaged in care at home. The Intensive Community Care Manager will assess, evaluate, and coordinate the team’s efforts to stabilize the most complex patients, with emphasis on safe transitions of care from facilities to primary care, outreach to patients who are not engaged in care, and development of comprehensive care plans. This role includes clinical supervision of team members and, for some positions, direct supervision of staff. The clinician will collaborate with PCPs to tailor plans of care to patient needs. This position adheres to departmental goals, standards of performance, regulatory compliance, and quality patient care protocols.
Essential duties include in-house, facility, and telephonic visits to high-risk patients to prevent hospital admissions; home visits for field nursing interventions; developing and reviewing care plans; discharge planning; supervising LPNs; conducting health assessments including social determinants of health; coordinating plans of care with PCPs and care teams; performing environmental risk assessments; evaluating caregiver capacity; providing patient and caregiver education; leading multidisciplinary team meetings when needed; assisting patients in navigating health system
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Essential duties include in-house, facility, and telephonic visits to high-risk patients to prevent hospital admissions; home visits for field nursing interventions; developing and reviewing care plans; discharge planning; supervising LPNs; conducting health assessments including social determinants of health; coordinating plans of care with PCPs and care teams; performing environmental risk assessments; evaluating caregiver capacity; providing patient and caregiver education; leading multidisciplinary team meetings when needed; assisting patients in navigating health system
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Based on: Intensive Community Care Manager (RN)
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