Community Nurse Case Manager (RN)

Job Overview The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) who works with our highest complexity patients, collaborating with primary care physicians and other care team members to deliver hyperfocused case management and field nursing interventions. The role prevents unnecessary hospital arrivals, keeps patients engaged in an intensive primary care model, and maximizes healthy time at home. Essential responsibilities Provide in‑home and telephonic visits to high‑risk patients to prevent unnecessary hospital admissions or ER visits. Conduct home visits for initial assessment, develop care plans, and complete follow‑up visits. Review patient charts for discharge and conduct final discharge discussions with patients. Perform supervisory visits with Practical Nurses (LPNs) to deliver education and oversee discharge from case management. Conduct clinical and social determinants of health (SDoH) assessments, including disease monitoring, medication monitoring, health education, and self‑care instructions. Coordinate and oversee the plan of care, ensuring it aligns with patient needs and community resources. Initiate case management assessments to determine outpatient needs. Ensure individual plans of care reflect patient needs and available benefits or community services. Complete plans with patients, families, and care team members; communicate instructions and methodologies for correct implementation. Assess the environment of care, caregiver capacity, and patient educational needs. Coordinate, report, document, and follow up on multidisciplinary team meetings. Assist patients in navigating health care systems and connect them with community resources. Facilitate and coach patients to use natural supports and mainstream community resources. Maintain ongoing communication with families, community providers, and others to promote health and well‑being. Establish supportive relationships to promote patient self‑management. Monitor quality, frequency, and appropriateness of outpatient services. Assist patient families with community/financial resources and refer cases to social workers as appropriate. Perform other duties as assigned or modified by management. Pay Hourly: $36.90–$52.70, depending on experience, education, geographic location, and other factors. Benefits Comprehensive benefits including base salary, potential bonuses or commissions, career development, and advancement opportunities. For more information, visit the benefits portal. #J-18808-Ljbffr ChenMed LLC