Job Description

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 include providing in home and telephonic visits to patients at high-risk for hospital admission and readmission, performing initial assessments and developing care plans, conducting supervisory visits with LPNs and patients, performing clinical and social determination of health screening assessments, coordinating the plan of care, communicating instructions, assessing environment and caregiver capacity, coordinating multidisciplinary team meetings, helping patients navigate health care systems, facilitating use of community resources, maintaining communication with families and providers, monitoring quality of visits and services, assisting with access to community/financial resources, and performing other duties as assigned. Knowledge, skills and abilities required include strong interpersonal and communication skills, critical thinking, autonomy, ability to monitor and adjust care plans, knowledge of nursing and case management theory and practice, proficiency in Microsoft Office, and willingness to travel locally and nationally. Education and experience criteria include an Associate degree in Nursing, a valid RN license, minimum 2 years clinical experience, 1 year case management experience preferred, valid driver’s license, and preferred Certified Case Manager certification. ChenMed is a family-owned, physician-led organization focused on improving healthcare for seniors through primary care innovation.

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