Community Nurse 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.

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 that provides 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.

The Intensive Community Managers (ICCMs) will serve as a clinical lead for the Complex Care Team. They will assess, evaluate, and coordinate the team’s efforts to stabilize our highest risk patients, with special areas of focus including safe transitions of care from facilities back to our primary care teams, stabilization of our highest risk ambulatory patients and outreach to patients who are assigned to us but are not engaged in care.

This person will perform assessments and design comprehensive plans of care, and drive the actions needed to keep the most complex patients safely s professional will also provide clinical supervision to other team members in delivering the plan of care and in other tasks necessary to meet their needs and engage them in care.

As a clinical leader for the team, this person will also be deeply involved in prioritizing team efforts and may also become the direct supervisor for some team members.

The Intensive Community Manager works in partnership with the PCPs to draft personalized care plans that address patient’s immediate needs that cause a risk for unnecessary hospital arrivals.

This position adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital .
• Provides home visits to perform initial assessment of patient and the development of care plan as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
• Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
• Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self‑care instructions in the outpatient in home setting.
• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
• Completes individual plan of cares with patients, family/care giver and care team members.
• Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assesses the environment of care, e.g., safety and security.
• Assesses the caregiver capacity and willingness to provide care.
• Assesses patient and caregiver educational needs.
• Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches’…