Intensive Community Manager, Complex Care; RN

The RN Community Care Nurse will serve as a clinical lead for a multidisciplinary community care team that cares for our highest complexity patients, coordinating care and stabilizing high‑risk patients through home visits, telephonic outreach, and collaboration with primary care physicians.

• Provide in-home and telephonic visits to patients identified as high risk for hospital admission or readmission to prevent ER or hospital use.
• Conduct initial assessments and develop individualized care plans for patients; use these plans to guide Licensed Practical Nurses during follow-up visits.
• Review patient charts after care management episodes, conduct final discharge discussions with patients.
• Supervise Licensed Practical Nurses and patients to provide additional education, oversee discharge, and ensure plan implementation.
• Perform clinical and social determinants of health screenings, including disease-oriented assessment, medication monitoring, health education, and self-care instructions.
• Coordinate and maintain clear plans of care, ensuring they reflect patient needs and available community resources.
• Communicate instructions and methodologies to all team members to ensure proper care implementation.
• Assess care environment safety, caregiver capacity, willingness, and educational needs.
• Coordinate, document, and follow up on multidisciplinary team meetings.
• Assist patients in navigating health-care systems, connecting them with community resources, and managing administrative and logistical tasks.
• Facilitate and coach patients in using natural supports and mainstream community resources.
• Maintain ongoing communication with families, community providers, and other stakeholders to promote patient health and well-being.
• Establish supportive and motivational relationships that support patient self-management.
• Monitor quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Help patients and families access community or financial resources and refer cases to social workers when appropriate.
• Conduct home visits under the direction of the primary care physician for urgent patient needs.
• Perform additional duties as assigned or modified by management.

$36.90-$52.70 per hour. Final compensation depends on experience, education, geographic location, and other factors. The position may also be eligible for bonuses or commissions.