Intensive Community Manager, Complex Care; RN

Intensive Community Manager, Complex Care (RN)

Join to apply for the Intensive Community Manager, Complex Care (RN) role at Chen Med.

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• Provides in‑home and telephonic visits to high‑risk patients to prevent admission or readmission.
• Conducts home visits for initial assessment and develops care plans for the LPN to follow up.
• Supervises LPN and patients during visits and oversees discharge from case management.
• Performs clinical and social determinants of health (SDoH) assessments, including disease monitoring, medication monitoring, health education and self‑care instructions.

• Provides oversight for the LPN with a clear plan of care and mandatory education.
• Conducts initial case‑management assessment to determine outpatient needs.
• Ensures individual plans reflect patient needs and available community services.
• Completes plans with patients, families and team members.
• Communicates instructions and methodologies to ensure correct implementation.
• Assesses care environment, caregiver capacity and educational needs.
• Coordinates, documents and follows up on multidisciplinary team meetings.
• Helps patients navigate healthcare systems and connect with community resources.
• Facilitates and coaches patients to use natural supports and mainstream resources.
• Maintains communication with families and community providers.
• Establishes supportive relationships to promote self‑management.
• Monitors quality, frequency and appropriateness of HHA visits and other services.
• Assists with community/financial resources and refers to social worker as needed.
• Performs urgent home visits under the primary care physician’s direction.
• Performs other duties as assigned.

$36.90 – $52.70 hourly (base rate; final compensation may include bonuses or commissions).

Mid‑Senior level

Full‑time

Current employee applicants: apply HERE. Current contingent workers: see job aid HERE to apply.