Community Care Nurse

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 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.

Coordinate the Plan of Care:

• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
• Completes individual plan of cares with patients, family/care giver  and care team members.
• Communicates instructions 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, reports, documents and follows-up on multidisciplinary team 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 tasks.
• Coordinates the delivery of services to effectively address patient needs.
• 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 of patients.
• 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.
• Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
• Performs other duties as assigned and modified at manager’s discretion.

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.
• Ability to plan, implement and evaluate individual patient care plans.
• Ability to work as oversight for License Practical Nurse (LPN) for initial assessments, plan of care and supervisory visits including proper discharge of a patient from case management.
• 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 a plus.
• This job requires use and exercise of independent judgment

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.