ChenMed
We’re unique. You should be, too.
We’re changing lives every day for our patients and team members. Are you innovative, entrepreneurial, and driven? Do you inspire others with kindness and joy?
We’re different from most primary care providers. As we rapidly expand, we need great people to join our team.
The Community Care team is a multidisciplinary service including Registered Nurses (RN), Licensed Practical Nurses (LPN), Community Social Workers (CSW), and Community Health Coordinators (CHC). We work with high-complexity patients and their primary care physicians to meet medical and social needs, aiming to fully engage patients in our intensive primary care model and maximize their time at home.
The Intensive Community Manager will serve as a clinical lead, coordinating efforts to stabilize high-risk patients, focusing on safe transitions of care, stabilization of ambulatory patients, and outreach to unengaged patients.
This role involves conducting initial assessments, designing care plans, providing clinical supervision, and prioritizing team efforts. The manager may also supervise some team members directly.
This position adheres to departmental goals, performance standards, regulatory compliance, and policies.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
Provide in-home and telephonic visits to high-risk patients to prevent hospital admissions and readmissions. Perform initial assessments and develop care plans for LPN follow-up visits. Review patient charts for discharge after care management episodes. Conduct supervisory visits with LPNs to provide education and oversee discharge processes. Perform clinical and Social Determination of Health (SDoH) assessments, including disease monitoring, medication management, health education, and self-care instructions. Coordinate the Plan of Care:
Oversee LPNs with clear care plans and education during visits. Conduct initial assessments to determine outpatient needs. Ensure care plans reflect patient needs and available community resources. Collaborate with patients, families, and care team members to develop care plans. Communicate instructions to ensure proper implementation. Assess the environment, caregiver capacity, and educational needs. Coordinate multidisciplinary team meetings and follow-up. Assist patients in navigating healthcare systems and connecting with community resources. Maintain ongoing communication with families and providers. Establish supportive relationships to promote self-management. Monitor quality and appropriateness of outpatient services. Assist with access to community and financial resources; refer to social workers as needed. Conduct home visits under physician direction for urgent needs. Perform other duties as assigned. EDUCATION AND EXPERIENCE CRITERIA:
Associate degree in Nursing required. Bachelor’s Degree in Nursing (BSN) or related field preferred. Valid RN license in the state of employment required. At least 2 years of clinical experience required. 1+ year of community case management experience highly desired. Certified Case Manager certification preferred. Valid driver’s license required. BLS certification from AHA or Red Cross required within 90 days of hire. We’re ChenMed, transforming healthcare for seniors and America’s healthcare system. Family-owned and physician-led, we focus on improving health and well-being. We’re growing rapidly to serve more seniors. We offer competitive pay, comprehensive benefits, career growth, and a great work-life balance. Join us and make a difference daily. Current Employee apply
HERE Current Contingent Worker see job aid
HERE
to apply
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Provide in-home and telephonic visits to high-risk patients to prevent hospital admissions and readmissions. Perform initial assessments and develop care plans for LPN follow-up visits. Review patient charts for discharge after care management episodes. Conduct supervisory visits with LPNs to provide education and oversee discharge processes. Perform clinical and Social Determination of Health (SDoH) assessments, including disease monitoring, medication management, health education, and self-care instructions. Coordinate the Plan of Care:
Oversee LPNs with clear care plans and education during visits. Conduct initial assessments to determine outpatient needs. Ensure care plans reflect patient needs and available community resources. Collaborate with patients, families, and care team members to develop care plans. Communicate instructions to ensure proper implementation. Assess the environment, caregiver capacity, and educational needs. Coordinate multidisciplinary team meetings and follow-up. Assist patients in navigating healthcare systems and connecting with community resources. Maintain ongoing communication with families and providers. Establish supportive relationships to promote self-management. Monitor quality and appropriateness of outpatient services. Assist with access to community and financial resources; refer to social workers as needed. Conduct home visits under physician direction for urgent needs. Perform other duties as assigned. EDUCATION AND EXPERIENCE CRITERIA:
Associate degree in Nursing required. Bachelor’s Degree in Nursing (BSN) or related field preferred. Valid RN license in the state of employment required. At least 2 years of clinical experience required. 1+ year of community case management experience highly desired. Certified Case Manager certification preferred. Valid driver’s license required. BLS certification from AHA or Red Cross required within 90 days of hire. We’re ChenMed, transforming healthcare for seniors and America’s healthcare system. Family-owned and physician-led, we focus on improving health and well-being. We’re growing rapidly to serve more seniors. We offer competitive pay, comprehensive benefits, career growth, and a great work-life balance. Join us and make a difference daily. Current Employee apply
HERE Current Contingent Worker see job aid
HERE
to apply
#J-18808-Ljbffr