Complex Care Nurse; RN

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?

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  ICCMs serve as a clinical lead for the Complex Care Team, assessing, evaluating, and coordinating team efforts to stabilize high‑risk patients, with special focus on safe transitions of care from facilities, stabilization of ambulatory patients, and outreach to patients not engaged in care.

This professional provides clinical supervision, prioritizes team efforts, and may become direct supervisor for some members. The Intensive Community Manager works in partnership with PCPs to draft personalized care plans that address patients’ immediate needs that pose a risk for unnecessary hospital arrivals. The position adheres to strict departmental goals, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

• Provides in‑house, at‑facility, and telephonic visits to patients at high risk for hospital admission and re‑admission (as identified by CM Plan) with the main goal of preventing unnecessary hospital arrivals for patients that have consented to the program and after successfully completing the full course of the program.
• Provides home visits to perform field nursing interventions, assess the patient, and develop a care plan to identify goals, barriers, and interventions that will be addressed during follow‑up visits. Once a patient has completed their episode of care management, the RN will review the chart for discharge and conduct the final discharge with the patient. Discharge from the program may require formal approval from Complex Care Leadership Team.
• Conducts supervisory visits with a Licensed Practical Nurse (LPN) and patient to provide any additional education the patient may need and to oversee appropriate discharge from case management.
• Performs clinical, fall prevention, and social determination of Health screening (SDoH) assessments to include disease‑oriented assessment and monitoring, medication monitoring, health education, and self‑care instructions in the outpatient in‑home setting.
• Performs home field nursing interventions agreed by PCP, Center Leadership, and Complex Care Leadership that would prevent hospital arrival, such as taking vital signs, weighing the patient, and other one‑time visits ordered by PCP and reviewed by the Manager for approval, as determined in Standard Operating Procedures (SOPs).

• Conducts/coordinates initial case management assessment of patients to determine outpatient needs and obtains patient consent to the program.
• Ensures individual plan of care reflects patient needs and services available in the community or reviews benefits.
• Completes individual plan of care intervention with patients, family/caregiver, and care team members focused on incremental actions to prevent unnecessary hospitalizations.
• Assesses the environment of care (e.g., safety and security) and conducts fall risk assessment as needed.
• Assesses the caregiver’s capacity and willingness to provide care.
• Assesses and educates patient and caregiver on educational needs.
• Coordinates, reports, documents, and follows up on multidisciplinary team meetings, serving as host or lead as needed.
• Helps patients navigate health‑care systems, connects them with community resources, orchestrates delivery of services, and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches patients in using natural support and mainstream community resources to address supportive needs.
• Maintains…