Nurse Case Manager 1 (RN)
Posted on: November 20, 2022
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 Nurse Case Manager 1 (RN) is responsible for achieving positive
patient outcomes and managing quality of care across the continuum
of care. The incumbent in this role will first and foremost serve
as an advocate for our patients. He/She works closely 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. The
Nurse Case Manager 1 (RN) role also involves establishing
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. He/She adheres to
strict departmental goals/objectives, standards of performance,
regulatory compliance, quality patient care compliance and policies
CORE JOB DUTIES/RESPONSIBILITIES:
- Manages and plans for transitions of care, discharge and post
discharge follow-up for patients admitted to key,
- Establishes a trusting relationship with patients and their
- 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
- 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
- Facilitates patient/family conferences to review treatment
goals and optimize resource utilization; provides family education
and identifies post-hospital needs.
- Serves as a patient advocate. Enhances a collaborative
relationship to maximize the patient/family's ability to make
- Addresses advanced care planning including treatment goals and
- Refers cases to social worker (Hospital and
ChenMed/JenCare/Dedicated) for complex psychosocial and economic
- Refers cases where patient and/or family would benefit from
counseling required to complete complex discharge plan to social
- Reports observed or suspected child or adult abuse pursuant to
- Obtains onsite and EMR access at priority facilities.
- Maintains clinical and progress notes for each patient
receiving care and provides progress report to PCP and others as
- Submits required documentation in a timely manner and in
appropriate computer system.
- Participates in surveys, studies and special projects as
- Conducts concurrent medical record review using specific
indicators and criteria as approved by medical staff. Acts as
patient advocate: investigates and reports adverse occurrences, and
performs staff education related to resource utilization, discharge
planning and psychosocial aspects of healthcare delivery.
- Promotes effective and efficient utilization of clinical
resources and mobilizes resources to assist in achieving desired
clinical outcomes within specific timeframe.
- Conducts review for appropriate utilization of services from
admission through discharge. Evaluates patient satisfaction and
quality of care provided.
- Communicates with physicians at regular intervals throughout
hospitalization and develops an effective working relationship.
Assists physicians to maintain appropriate cost, case and desired
- Coordinates the provision of social services to patients,
families and significant others to enable them to deal with the
impact of illness on individual family functioning and to achieve
maximum benefits from healthcare services.
- Completes expanded assessment of patients and family needs at
time of admission. Completes psychosocial assessment.
- Directs and participates in the development and implementation
of patient care policies and protocols to provide advice and
guidance in handling unusual cases or patient needs.
- Attends meetings as assigned
- Performs other duties as assigned and modified at manager's
Community Case Manager ( primarily clinic and community based )
Responsibilities include all the above "Core"
duties/responsibilities plus the following :
- 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, to
disease management patients per the Disease Management Plan and to
others as referred via transitional care team, acute case managers
and Transitional Care 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.
Coordinate 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
- Makes recommendations to the team.
- Completes individual plan of care with patients and team
- Communicates instructions and methodologies as appropriate to
ensure that the plan is implemented correctly.
- Assesses the environment of care, e.g., safety and
- Assesses the caregiver capacity and willingness to provide
- Assesses patient and caregiver educational needs.
- Coordinates, reports, documents and follows-up on Super Huddles
and HPP/IDT meetings.
- Helps patients navigate health care systems, connecting them
with community resources; orchestrates multiple facets of health
care delivery and assists with administrative and logistical
- Coordinates the delivery of services to effectively address
- Facilitates and coaches 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
- Establishes a supportive and motivational relationship with
patients that support patient self-management
- 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.
KNOWLEDGE, SKILLS AND ABILITIES:
- Strong interpersonal and communication skills and the ability
to work effectively with a wide range of constituencies in a
- Critical thinking skills required.
- Ability to work autonomously is required.
- Ability to monitor, assess and record patients' progress and
adjust and plan accordingly.
- Ability to plan, implement and evaluate individual patient care
- Knowledge of nursing and case management theory and
- 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
- 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
- Ability and willingness to travel locally, regionally and
nationwide up to 10 % of the time.
- Spoken and written fluency in English.
- Bilingual preferred.
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
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
EDUCATION AND EXPERIENCE CRITERIA:
- Associate degree in Nursing required.
- Bachelor Degree in Nursing (BSN) or RN with Bachelor Degree in
a related clinical field preferred.
- A valid, active Registered Nurse (RN) license in State of
- A minimum of 2 years' clinical work experience required.
- A minimum of 1 year of utilization review and/or case
management, home health, discharge planning experience
- A minimum of 1 year of case management experience in acute case
management or community case management experience highly
- Certified Case Manager certification is preferred.
Certification through the Commission for Case Manager Certification
(CCMC) or the American Association of Managed Care Nurses (CMCN)
- This position requires possession and maintenance of a current,
valid Driver's License
- Must have $100,000 No-Fault or Personal Injury (PIP)/$300,000
Property Damage Liability (PDL) Limits requirement on the personal
automobile insurance policy
Keywords: ChenMed, Bradenton , Nurse Case Manager 1 (RN), Healthcare , Bradenton, Florida
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