ChenMed · 1 day ago
Intensive Community Manager, Complex Care (RN)
Fort Myers, FL
Full-time
Onsite
Mid, Senior Level
$36.90/hr - $52.70/hr
2+ years expChenMed is transforming healthcare for seniors and changing America’s healthcare for the better. The Intensive Community Care Manager (ICCM) is a Registered Nurse who works with high complexity patients to provide case management and field nursing interventions aimed at preventing unnecessary hospital admissions and maximizing healthy time at home.
Health CarePrimary and Urgent Care
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)
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 Clinica Strategy Team such as Hospital Care Managers and Post Hospital Care Coordinators and Manages to ensure patients in their program receive holistic care approval
Home visit under the direction of the patient’s primary care physician to meet urgent patient needed with the aim of preventing unnecessary hospital arrivals
Performs other duties as assigned and modified at manager’s discretion
Qualification
Required
Associate degree in Nursing required
A valid, active Registered Nurse (RN) license in State of employment required. Compact License preferred for states where compact license is available
A minimum of 2 years' clinical work experience required
Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment
Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
Critical thinking skills
Ability to work autonomously
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
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
Bilingual a plus
Benefits
Comprehensive benefits
Career development and advancement opportunities
Great work-life balance
Company
ChenMed
ChenMed is a full-risk primary care market leader that is transforming healthcare for seniors.
1001-5000 employees
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)
Funding
Current Stage
Late StageLeadership Team
Christopher Chen, MD
Chief Executive Officer
Michael Redmond
Chief Financial Officer
Recent News
2025-06-27
Google Patent
2025-05-05
Company data provided by crunchbase