Community Nurse Case Manager - Case Management
Posted on: November 19, 2023
Community Nurse Case ManagerWe're unique. You should be,
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.
Community Care nurses, Licensed Practical Nurse (LPN) Community
Care nurses, Community Social Workers (CSW) and Community Health
Coordinator (CHC) who work with our highest complexity patients and
their primary care physicians to meet their medical and social
needs with the aims of fully engaging them in our intensive primary
care model and maximizing their healthy time at home.
The Register Nurse (RN) Community Care Nurse will serve as a
clinical lead for a Community Care team. They will 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 initial
assessments and design comprehensive plans of care for many of
these patients. This 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.
This position adheres to strict departmental goals/objectives,
standards of performance, regulatory compliance, quality patient
care compliance and policies and procedures
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
* 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
* Provides home visits to perform initial assessment of patient and
the development of care plan for the Licensed Practical Nurse (LPN)
to use 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
* 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.
Coordinate the Plan of Care:
* Provides oversight for the License Practical Nurse (LPN) with
clear plan of care and education which is mandatory during all LPN
* 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
* 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
* 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
* Facilitates and coaches' patients in using natural supports and
mainstream community resources to address supportive needs.
* Maintains ongoing communication with families, community
providers and others as needed to promote the health and well-being
* Establishes a supportive and motivational relationship with
patients that support patient self-management
* Monitors the quality, frequency, and appropriateness of HHA
visits and other outpatient services.
* Assists patient and family with access to community/financial
resources and refer cases to social worker as appropriate.
* Home visit under the direction of the patient's primary care
physician to meet urgent patient needed.
* Performs other duties as assigned and modified at manager's
KNOWLEDGE, SKILLS AND ABILITIES:
* Strong interpersonal and communication skills and the ability to
work effectively with a wide range of constituencies in a diverse
* Critical thinking skills required.
* Ability to work autonomously is required.
* Ability to monitor, assess and record patients' progress and
adjust and plan accordingly.
* Ability to plan, implement and evaluate individual patient care
* Ability to work as oversight for License Practical Nurse (LPN)
for initial assessments, plan of care and supervisory visits
including proper discharge of a patient from case management.
* Knowledge of nursing and case management theory and practice.
* Knowledge of patient care charts and patient histories.
* Knowledge of clinical and social services documentation
procedures and standards.
* Knowledge of community health services and social services
support agencies and networks.
* Organizing and coordinating skills.
* Ability to communicate technical information to non-technical
* Proficient in Microsoft Office Suite products including Excel,
Word, PowerPoint, and Outlook, plus a variety of other
word-processing, spreadsheet, database, e-mail and presentation
* Ability and willingness to travel locally, regionally, and
nationwide up to 10% of the time.
* Spoken and written fluency in English. Bilingual a plus.
* This job requires use and exercise of independent judgment
EDUCATION AND EXPERIENCE CRITERIA:
* Associate degree in Nursing required.
* Bachelor's Degree in nursing (BSN) or RN with bachelor's degree
in home in a related clinical field preferred.
* A valid, active Registered Nurse (RN) license in State of
* A minimum of 2 years' clinical work experience required.
* A minimum of 1 year of case management experience in community
case management experience highly desired.
* This position requires possession and maintenance of a current,
valid driver's license.
* Certified Case Manager certification is preferred. Certification
through the Commission for Case Manager Certification (CCMC) or the
American Association of Managed Care Nurses (CMCN) desired.
We're ChenMed and we're transforming healthcare for seniors and
changing America's healthcare for the better. Family-owned and
physician-led, our unique approach allows us to improve the health
and well-being of the populations we serve. We're growing rapidly
as we seek to rescue more and more seniors from inadequate health
ChenMed is changing lives for the people we serve and the people we
hire. With great compensation, comprehensive benefits, career
development and advancement opportunities and so much more, our
employees enjoy great work-life balance and opportunities to grow.
Join our team who make a difference in people's lives every single
Keywords: ChenMed, Chicago , Community Nurse Case Manager - Case Management, Executive , Chicago, Illinois
Didn't find what you're looking for? Search again!