RN Case Manager

About this role

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.

*This position is an on-site role requiring hours Monday through Friday (7:30am-4:30pm or 8:00am-5:00pm). This role requires being both on-site at the healthcare office as well as in home patient visits supporting patients from our West Philadelphia office and our North Philadelphia office.

The Intensive Community Care Manager (ICCM) is a Registered Nurse (RN) who works with our highest complexity patients, their primary care physicians, and other members of the care team that provides hyperfocus case management and field nursing interventions to prevent unnecessary hospital arrivals, keep patients engaged in our intensive primary care model and maximize their healthy time at home.

The Intensive Community Managers (ICCMs) will serve as a clinical lead for the Complex Care Team. They will assess, evaluate, and 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 assessments and design comprehensive plans of care, and drive the actions needed to keep the most complex patients safely at home. 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. The Intensive Community Manager works in partnership with the PCPs to draft personalized care plans that address patient’s immediate needs that cause a risk for unnecessary hospital arrivals.

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-house, at facility, and telephonic visits to patients at high-risk for hospital admission and re-admission (as identified by CM Plan) with the main goal of preventing unnecessary hospital arrivals for patients that have consented to the program and after successfully completed full course of program.

• Provides home visits to perform field nursing interventions, assess patient, and the development of care plan to identify the goals, barriers, and interventions that will be addressing during the follow up patient visits. Once a patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient. Discharge from program may require formal approval from Complex Care Leadership Team

• 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, fall prevention, 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.

• Performs home field nursing interventions that have been agreed by PCP, Center Leadership, and Complex Care Leadership that would prevent hospital arrival. Such intervention may include taking vital signs, weighing patient, appropriate one time visits ordered by PCP and reviewed by the Manager for approval, and others as determined in Standard Operation Procedures (SOPs)

Coordinate the Plan of Care: • Conducts/coordinates initial case management assessment of patients to determine outpatient needs and obtains patients consent to program.

• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.

• Completes individual plan of care intervention with patients, family/care giver  and care team members with a focus of incremental actions that will prevent unnecessary hospitalizations.

• Assesses the environment of care, e.g., safety and security. Conduct fall risk assessment as needed.

• Assesses the caregiver’s capacity and willingness to provide care.

• Assesses and educations patient and caregiver educational needs.

• Coordinates, reports, documents and follows-up on multidisciplinary team meetings serving as host or lead for those conversations as needed.

• 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 support 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 patients and family with access to community/financial resources and refer cases to social worker and other programs available as appropriate.

• Collaborates closely with other members of the Complex Care and Clinical Strategy Team such as Hospital Care Managers and Post Hospital Care Coordinators and Man

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