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 overall goal of the Nurse Case Manager position is to achieve positive patient outcomes and manage quality of care across the continuum of care. The nurse case manager will first and foremost serve as an advocate for our patients. In this capacity, they will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The nurse case manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Manages and plans for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.

• 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 implement actions as appropriate.

• Builds relationships with preferred acute care providers (hospitalists, specialists).

• 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, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.

• Keeps the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.

• Introduces self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.

• Provides high intensity engagement with patient and family.

• Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.

• Enhances a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions.

• Addresses advanced care planning including treatment goals and advance directives.

• Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.

• Obtains onsite and EMR access at priority facilities.

• Maintains clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.

• Submits required documentation in a timely manner and in appropriate computer system.

• Participates in surveys, studies and special projects as assigned.

• Other duties as assigned and modified at manager’s discretion.

There are 4 Nurse Case Manager Roles With Additional Essential Job Functions:

Acute Case Manager (primarily hospital based)

Responsibilities include but are not limited to:

• 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 patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.

• In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.

• When patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.

• Validates appropriateness of inpatient vs. observation status.

• Facilitates discharge to appropriate level of care and preferred providers.

• Coordinates acute UR physician meetings.

Community Case Manage r (primarily clinic and community based)

Responsibilities Include but are not limited to:

• Provides telephonic or outpatient visits to patients at high risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, and to others as referred via transitional care team, acute case managers and IDT team.

• Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.

• Performs clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.

• Coordinates the Plan of Care:

• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.

• Ensures individual plan of care reflects patient needs and services available.

• Makes recommendations to the team.

• Completes individual plan of care with patients and team members.

• Communicates instruction and methodologies as appropriate to ensure that the plan is implemented correctly.

• Assesses the environment of care, e.g., safety and security.

• Assesses the caregiver capacity and willingness to provide care.

• Assesses patient and caregiver educational needs.

• Coordinates, documents and follow-ups on IDT meetings.

• Reports observed or suspected child or adult abuse pursuant to mandated requirements.

• Helps patients navigate health care systems, connecting them with community resources, orchestrate multiple facets of health care delivery, and assist with administrative and logistical tasks.

• Coordinates the delivery of services to effectively address patient needs.

The overall goal of the Nurse Case Manager position is to achieve positive patient outcomes and manage quality of care across the continuum of care. The nurse case manager will first and foremost serve as an advocate for our patients. In this capacity, they will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The nurse case manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

• Facilitates and coach patients in using natural supports and mainstream community resources to address supportive needs.

• Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.

• Establishes a supportive and motivational relationship with patients that support patient self-management

• Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify home needs.

• Monitors the quality, frequency and appropriateness of HHA visits and other outpatient services.

• Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.

Community/Skilled Nursing Facility Case Manager (Community Case Manager Role with additional SNF duties as assigned)

Responsibilities include but are not limited to:

• Community Case Manager role as above.

• CM telephonic or onsite visits to SNFs, communication with PT, social workers, patient and families as appropriate.

• Validates appropriate level of care/LOS.

• Validates Discharge plan for safe transition home, utilization of preferred providers or timely transition to long term care.

• PCP 4 day follow-up visit.

• Collaborates with Humana Onsite SNF CM3.

Transitional Case Manager (Blended Acute and Community Case Manager Roles)

Responsibilities include but are not limited to:

• Onsite patient visitation, risk assessment, and care coordination in the acute and community settings.

• Discharges needs assessment and planning.

• Assists patient with engaging community resources.

• Posts discharge telephone calls with medication reconciliation.

• Posts discharge follow up appointment scheduling.

• Home visits with case management assessment including risk and needs assessments.

• Ongoing monitoring of high risk patients with select conditions (congestive heart failure, chronic obstructive pulmonary disease, etc.)

• Multidisciplinary case conferences.

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong interpersonal, communication and critical thinking skills are required.

• Ability to work autonomously is required.

• Fluent in English.

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.

• Critical thinking skills required.

• Ability to work autonomously is required.

• Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.

• Understanding utilization review and how to leverage with inpatient staff for possible reduction of medical cost on long length of stay patients.

• 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.

• Knowledge of community health services and social services support agencies and networks.

• Organizing and coordinating skills.

• Ability to communicate technical information to non-technical personnel.

• Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.

• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.

• Spoken and written fluency in English, bilingual preferred.

• Associate degree in Nursing required.

EDUCATION AND EXPERIENCE CRITERIA:

• Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree 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 utilization review and/or case management, home health, hospital discharge planning experience required.

• A minimum of 1 year of case management experience in acute case management or community case management experience highly desired.

• This position requires possession and maintenance of a 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.

We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care.

ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day.

Current Employee apply HERE (https://careers.chenmed.com/i/us/en/homerevisited)

Current Contingent Worker please see job aid HERE to apply