Intensive Community Manager, Complex Care (RN)

Overview The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care. The incumbent serves as an advocate for patients, works closely with the care team to develop effective plans of care, and maintains high levels of care coordination. Key Responsibilities Manage and plan transitions of care, discharge, and post‑discharge follow‑up for patients admitted to key, high‑volume/high‑priority hospitals. Establish and maintain trusting relationships with patients and their caregivers. Collaborate with clinical staff to develop and execute plans of care and achieve goals. Report variations to PCP/Transitional Care Physicians and implement appropriate actions. Build relationships with preferred acute care providers and direct referrals. Coordinate integration of social services and case management functions in pre‑acute, ER, acute, and post‑acute settings. Coordinate patient care, discharge, and home‑planning processes with hospital case‑management departments and other healthcare facilities. In conjunction with PCP, hospitalist, medical director, insurance case manager, and hospital case manager, coordinate patient transition to the appropriate or least restrictive level of care using a preferred provider. Keep PCP aware of patient condition via e‑mail, DASH, HITS, or other communication methods. Introduce self to patient/family, explain the Nurse Case Manager’s role, and provide processes for contact. Provide high‑intensity engagement with patient and family. Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide education, and identify post‑hospital needs. Serve as patient advocate and enhance collaborative relationships to maximize patient/family decision‑making. Address advanced care planning, including treatment goals and advance directives. Refer cases to social workers for complex psychosocial and economic needs. Report suspected child or adult abuse pursuant to mandated requirements. Obtain onsite and EMR access at priority facilities. Maintain clinical and progress notes for each patient and provide progress reports to PCP and others as appropriate. Submit required documentation in a timely manner and in the appropriate computer system. Participate in surveys, studies, and special projects as assigned. Conduct concurrent medical record reviews using approved indicators and criteria. Investigate and report adverse occurrences, and perform staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery. Promote effective and efficient utilization of clinical resources and mobilize resources to achieve desired clinical outcomes within defined timeframes. Review appropriate utilization of services from admission through discharge. Evaluate patient satisfaction and quality of care provided. Communicate with physicians at regular intervals and develop effective working relationships. Assist physicians in maintaining appropriate cost, case, and desired patient outcomes. Coordinate provision of social services to patients, families, and significant others to address the impact of illness and maximize benefits. Complete expanded assessment of patients and family needs at admission. Conduct psychosocial assessments. Direct and participate in development and implementation of patient care policies and protocols. Attend meetings as assigned. Perform other duties as assigned and modified at manager’s discretion. Additional Role Functions Acute Case Manager Identify appropriateness of inpatient versus observation status. Identify and manage safety risk, functional status (ADLs and PT needs), medication self‑management deficiencies, and correct knowledge deficits. Implement the ACM Coaching program for the appropriate patient population. Coordinate transition to a lower level of care for SNF patients, including preferred provider use. Facilitate discharge to appropriate level of care and preferred providers. Communicate discharge to all stakeholders, including PCP, Center Manager, and Community Case Manager. Document medical discharge dates and update appropriately. Arrange for a follow‑up PCP appointment before discharge and communicate this information to patients/caregivers. Discuss eligibility for CCM or DM programs and gauge patient interest. Coordinate acute UR physician meetings. Community Case Manager Provide telephonic or outpatient visits to high‑risk patients for readmission prevention, disease management, and other transitional care referrals. Perform clinical functions: disease‑oriented assessment, medication monitoring, health education, and self‑care instructions in the outpatient setting. Coordinate the Plan of Care by conducting initial case management assessments and ensuring plans reflect patient needs and available services. Make recommendations and complete individual plans of care with patients and team members. Communicate instructions and methodologies to ensure correct implementation. Assess safety, security, caregiver capacity, and willingness to provide care. Assess patient and caregiver educational needs. Coordinate and follow up on Super Huddles and HPP/IDT meetings. Help patients navigate healthcare systems and connect them with community resources. Coach patients in using natural supports and mainstream community resources. Maintain ongoing communication with families, community providers, and others to promote health and well‑being. Establish a supportive and motivational relationship with patients to support self‑management. Monitor quality, frequency, and appropriateness of HHA visits and other outpatient services. Assist patients with access to community/financial resources and refer to social workers as appropriate. Community/Skilled Nursing Facility Case Manager Perform community case management duties plus telephonic or onsite visits to SNFs. Communicate with physical therapists, social workers, patients, and families as appropriate. Validate appropriate level of care/LOS and discharge plan for safe transition home or long‑term care. Remind patients of the need for a 4‑day post‑hospital/SNF discharge PCP visit and future visits. Collaborate with payor onsite SNF case managers. Transitional Case Manager Combine acute and community case manager responsibilities as described above. Qualifications Strong interpersonal and communication skills to work effectively with diverse constituencies. Critical thinking and autonomous work abilities. Ability to monitor, assess, and record patient progress, and adjust plans accordingly. Ability to plan, implement, and evaluate individual patient care plans. Knowledge of nursing and case management theory, practice, commercial and social services documentation procedures, and community health services. Organizing and coordinating skills. Proficiency in Microsoft Office Suite and related software. Willingness to travel locally, regionally, and nationwide up to 10% of the time. Fluency in English; bilingual preferred. Pay Range $36.90 – $52.70 hourly. Final compensation depends on experience, education, geographic location, and other factors. This position may also be eligible for bonuses or commissions. Benefits Employee Benefits: #J-18808-Ljbffr ChenMed LLC