Intensive Community Manager, Complex Care (RN)
Jacksonville, FL (On-site)
Posted 2 months ago
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Job Summary
Coordinate transitions of care across inpatient, ER, and post-acute settings while building trusted relationships with patients, families, and providers to ensure smooth discharge planning and goal achievement.
- Owns end-to-end care coordination across settings
- Engages patients and families with clear guidance and education
- Collaborates with PCPs, hospitalists, and case management teams to optimize resource use
Job Description
Responsibilities
- Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
- Establishes a trusting relationship with patients and their caregivers.
- Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
- Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
- Directs referrals to preferred providers.
- Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
- In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
- Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication.
- Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education.
- Provides high intensity engagement with patient and family.
Requirements
- The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care.
- RN
- Strong interpersonal and communication skills
- Critical thinking skills
- Ability to work autonomously
- Ability to monitor, assess and record patients’ progress and adjust and plan accordingly
- Ability to plan, implement and evaluate individual patient care plans
- Knowledge of nursing and case management theory and practice
- Knowledge of patient care charts and patient histories
- Knowledge of clinical and social services documentation procedures and standards
Preferred
- Bilingual preferred.
ChenMed
We’re on a mission.To change lives. And to change healthcare.ChenMed serves underserved – moderate-to-low-income seniors with complex chronic diseases. Our high-touch, VIP, preventive primary care works. For our patients. And our team members.Unlike typical primary care providers, we have a much lower doctor-patient ratio which allows us to spend more time with our patients, getting to know them and their concerns so we can better serve them. Practicing medicine, the way it was meant to be practiced. We are known to our patients as Dedicated Senior Medical Center, Chen Senior Medical Center, or JenCare Senior Medical Center. With 100+ centers in 15 states, our privately held, physician-led company is featured in Fortune’s 2020 “Change The World” list, listed as a “Great Places To Work” 2022, 2023, and listed as one of Newsweek's "Most Loved Places to Work" for 2021 and 2022. We offer competitive compensation/benefits, a great mission-driven culture and so much more.
