The Community Care team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home.
The Register Nurse (RN) Community Care Nurse will serve as a clinical lead for a Community Care team. They will coordinate the team’s efforts to stabilize our highest risk patients, with special areas of focus including safe transitions of care from facilities back to our primary care teams, stabilization of our highest risk ambulatory patients and outreach to patients who are assigned to us but are not engaged in care. This person will perform initial assessments and design comprehensive plans of care for many of these patients. This professional will also provide clinical supervision to other team members in delivering the plan of care and in other tasks necessary to meet their needs and engage them in care. As a clinical leader for the team, this person will also be deeply involved in prioritizing team efforts and may also become the direct supervisor for some team members.
This position adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
- Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital .
- Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
- Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
- Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.
EDUCATION AND EXPERIENCE CRITERIA:
- Associate degree in Nursing required.
- Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in home in a related clinical field preferred.
- A valid, active Registered Nurse (RN) license in State of employment required.
- A minimum of 2 years’ clinical work experience required.
- A minimum of 1 year of case management experience in community case management experience highly desired.
- This position requires possession and maintenance of a current, valid driver’s license.
- Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.
Job Type: Full-time
Pay: $45.00 - $54.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Free parking
- Health insurance
- Health savings account
- Life insurance
- Mileage reimbursement
- Paid sick time
- Paid time off
- Referral program
- Retirement plan
- Vision insurance
- Wellness program
Medical specialties:
- Cardiology
- Geriatrics
- Home Health
- Medical-Surgical
- Primary Care
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Work setting:
- Acute care
- Clinic
- Office
- Outpatient
Application Question(s):
- Are you willing to make home visits to patients?
Education:
Experience:
- Clinical: 2 years (Required)
- Utilization review: 1 year (Required)
- Case management: 1 year (Preferred)
- Home health: 1 year (Required)
- Discharge planning: 1 year (Required)
License/Certification:
- RN License (Required)
- Driver's License (Required)
- Certified Case Manager (Preferred)
Work Location: In person