Intensive Community Manager, Complex Care; RN

Intensive Community Manager, Complex Care (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 to provide 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.

The Intensive Community Managers (ICCMs) will serve as a clinical lead for the Complex Care Team. They will assess, evaluate, and coordinate the team’s efforts to stabilize our highest-risk patients, focusing on safe transitions of care, stabilization of high-risk ambulatory patients, and outreach to patients not engaged in care. This professional will perform assessments, design comprehensive plans of care, and drive actions needed to keep the most complex patients safely y will also provide clinical supervision to other team members, prioritize team efforts, and may serve as direct supervisor for some team members.

The Intensive Community Manager works in partnership with PCPs to draft personalized care plans addressing patients’ immediate needs that risk unnecessary hospital arrivals.

This position adheres to strict departmental goals/objectives, 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.
• Provides home visits to perform field nursing interventions, assess patients, and develop care plans addressing goals, barriers, and interventions for follow-up visits. Upon completion of care management, reviews patient chart for discharge and conduct final discharge with patient. Discharge may require formal approval from Complex Care Leadership Team.
• Conducts supervisory visits with LPN and patient to provide additional education and oversee appropriate discharge from case management.
• Performs clinical, fall prevention, and social determination of health (SDoH) assessments: 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 to prevent hospital arrival, such as taking vital signs, weighing patient, one-time visits ordered by PCP and reviewed by the Manager, and others as determined in SOPs.

• Conducts/coordinates initial case management assessment to determine outpatient needs and obtain patient consent to program.
• Ensures individual plan of care reflects patient needs and services available in the community or review of benefits.
• Completes individual plan of care intervention with patients, family/caregiver, and care team focusing on incremental actions to prevent hospitalizations.
• Assesses the environment of care, e.g., safety and security; conducts fall risk assessment as needed.
• Assesses and educates caregiver regarding capacity and willingness to provide care.
• 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 multiple facets of health care delivery, and assists with administrative and logistical tasks.
• Coordinates delivery of services to meet patient needs effectively.
• Facilitates and coaches patients in using natural support and mainstream community resources for supportive needs.
• Maintains ongoing communication with families, community providers, and others to promote health and well-being.
• Establishes a…