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ChenMed · 13 hours ago

Intensive Community Manager (RN)

Houston, TX

Full-time

Onsite

Entry, Mid Level

$35.80/hr - $51.17/hr

2+ years exp

ChenMed is transforming healthcare for seniors and changing America’s healthcare for the better. The Intensive Community Manager will serve as a clinical lead for a Community Care team, coordinating efforts to stabilize high-risk patients and ensuring comprehensive care plans are developed and implemented effectively.

Health CarePrimary and Urgent Care

H1B Sponsor Likely

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

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

Qualification

Registered Nurse (RN) licenseCase management experienceClinical supervisionCertified Case ManagerBasic Life Support (BLS)Team coordinationPatient educationCommunication skills

Required

Associate degree in Nursing required

A valid, active Registered Nurse (RN) license in State of employment required

A minimum of 2 years' clinical work experience required

This position requires possession and maintenance of a current, valid driver's license

Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment

Preferred

Bachelor's Degree in nursing (BSN) or RN with bachelor's degree in home in a related clinical field preferred

A minimum of 1 year of case management experience in community case management experience highly desired

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

Benefits

Great compensation

Comprehensive benefits

Career development and advancement opportunities

Great work-life balance

Company

ChenMed

Glassdoor2.9

ChenMed is a full-risk primary care market leader that is transforming healthcare for seniors.

Founded in 1985

Miami, Florida, USA

1001-5000 employees

http://www.chenmed.com/

H1B Sponsorship

ChenMed has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (7)

2024 (4)

2023 (13)

2022 (26)

2021 (31)

2020 (23)