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ChenMed · 6 hours ago

RN Acute Care Manager

Newport News, VA

Full-time

Onsite

Mid Level

$35.80/hr - $51.17/hr

ChenMed is transforming healthcare for seniors and changing America’s healthcare for the better. The RN Acute Care Manager is responsible for achieving positive patient outcomes and managing quality of care across the continuum, serving as an advocate for patients and coordinating care with various healthcare providers.

Health CarePrimary and Urgent Care

H1B Sponsor Likely

Responsibilities

Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals

Establishes a trusting relationship with patients and their caregivers

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 facilities

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 family

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 informed decisions

Addresses advanced care planning including treatment goals and advance directives

Refers cases to social worker (Hospital and ChenMed/JenCare/Dedicated) for complex psychosocial and economic needs

Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker

Reports observed or suspected child or adult abuse pursuant to mandated requirements

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 appropriate

Submits required documentation in a timely manner and in appropriate computer system

Participates in surveys, studies and special projects as assigned

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 patient outcomes

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 discretion

Identify appropriateness of inpatient vs. observation status

Identify and manage safety risk (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits

Implement the ACM Coaching program with the appropriate patient population

In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed

Facilitate discharge to appropriate level of care and preferred providers

Communicate discharge to all stakeholders including PCP, Center Manager and Community Case Manager

Document the appropriate date that the patient is medically discharged and update as appropriate

Contact the center manager to arrange for a follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver

As appropriate, discuss patients’ eligibility for CCM or DM programs and identify patient interest in participation

Coordinate acute UR physician meetings

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

Conducts/coordinates initial case management assessment of patients to determine outpatient needs

Ensures individual plan of care reflects patient needs and services available

Makes recommendations to the team

Completes individual plan of care with patients and 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 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 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

Community Case Manager role as above

CM telephonic or onsite visits to SNFs, communication with physical therapists (PT), social workers, patient and families as appropriate

Validates appropriate level of care/LOS

Validates Discharge plan for safe transition home, utilization of preferred providers or timely transition to long term care

Reminds patient of need for 4-day PCP post hospital/SNF discharge visit and future visits

Collaborates with payor onsite SNF CMs

Acute and Community Case Manager roles as above

Qualification

NursingCase ManagementPatient AdvocacyCritical ThinkingMicrosoft Office SuiteCommunity Health ServicesCommunication SkillsBilingual PreferredOrganizing SkillsAutonomous Work

Required

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

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

Preferred

Bilingual preferred

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 (6)

2024 (4)

2023 (13)

2022 (26)

2021 (31)

2020 (23)