Complex Care Nurse; 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.

• ICCMs serve as a clinical lead for the Complex Care Team, assessing, evaluating, and coordinating team efforts to stabilize highest risk patients, including safe transitions from facilities, stabilization of ambulatory patients, and outreach to non-engaged patients. They perform assessments, design comprehensive plans of care, and drive actions needed to keep the most complex patients safely y provide clinical supervision, prioritize team efforts, and may become direct supervisors.

• Works in partnership with PCPs to draft personalized care plans addressing immediate patient needs that risk unnecessary hospital arrivals.

• This 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 high‑risk patients to prevent unnecessary hospital arrivals for consenting patients who have completed the program.

• Provides home visits for field nursing interventions, assessing patients and developing care plans. Upon entry into program, the RN reviews discharge and conducts final discharge. Discharge from program may require approval from Complex Care Leadership Team.

• Conducts supervisory visits with LPN and patient to provide education and oversee appropriate patient discharge.

• Performs clinical, fall prevention, and social determination of health screening assessments, disease monitoring, medication monitoring, health education, and self‑care instructions in outpatient home settings.

• Performs agreed‑upon home field nursing interventions, such as vital signs, weighing, PCP‑ordered visits, approved by Manager.

• Initial case‑management assessment to determine outpatient needs and obtain patient consent.

• Ensures the plan of care reflects patient needs and community resources.

• Completes plan intervention with patient, family, and care team to prevent hospitalizations.

• Assesses environment, safety, fall risk, caregiver capacity, and education needs.

• Coordinates, reports, documents, and follows up on multidisciplinary team meetings, hosting as needed.

• Helps patients navigate health‑care systems and connects them with community resources, assisting with administrative and logistical tasks.

• Coordinates the delivery of services to meet patient needs.

• Facilitates coaching patients using community resources.

• Maintains communication with families and community providers to promote health and well‑being.

• Establishes supportive relationships with patients to support self‑management.

• Monitors quality, frequency, and appropriateness of visits and services.

• Assists patients and families with community and financial resources, refer cases to social worker as appropriate.

• Collaborates with Complex Care and Clinical Strategy Team and other managers for holistic care approval.

• Conducts home visits per physician direction to address urgent needs and prevent arrivals.

• Performs additional duties as assigned.

• Strong interpersonal and communication skills; effective with diverse constituents.

• Critical thinking and autonomous work ability.

• Monitoring, assessing, recording patient progress; adjusting plans.

• Planning, implementing, evaluating patient care plans.

• Knowledge of nursing and case management…