**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. The Community Care Nurse is responsible for enhancing the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integrating and functions of case management, utilization review and discharge planning. The incumbent in this role adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures. **ESSENTIAL JOB DUTIES/RESPONSIBILITIES:** + Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other departments, external service organizations, agencies and healthcare facilities. + Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. + Acts as a 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 in maintaining appropriate cost, case and desired patient outcomes. **_Other responsibilities may include:_** + 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. + Refers cases where patients and/or family would benefit from counseling to complete complex discharge plan to social worker. + Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions. + Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post-hospital needs. + Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling special cases or patient needs. + Performs other duties as assigned and modified at manager’s discretion. KNOWLEDGE, SKILLS AND ABILITIES: + Thorough knowledge of case management principles, healthcare management and reimbursement. + Strong written and verbal communication skills; presentation skills. + Ability to convey medical terms and treatment plans so they are understood by patients and their caregivers. + Excellent organizational and time management skills. + Astute problem-solving skills with the ability to multi-task. + Compassionate and empathetic demeanor with the ability to work both independently and in a group/team environment. + General computer knowledge and effective Microsoft Office Products (PowerPoint, Excel, Word and Outlook) skills, plus the ability to use a variety of other word-processing, spreadsheet, database, e-mail and presentation software. + Ability and willingness to travel locally, regionally and/or nationwide up to 10% of the time. + Spoken and written fluency in English. KNOWLEDGE, SKILLS AND ABILITIES: + 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. + Ability to work as oversight for License Practical Nurse (LPN) for initial assessments, plan of care and supervisory visits including proper discharge of a patient from case management. + 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. Bilingual a plus. + This job requires use and exercise of independent judgment EDUCATION AND EXPERIENCE CRITERIA: + Associate degree in Nursing required. + Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in home in a related clinical field preferred. + A valid, active Registered Nurse (RN) license in State of employment required. + A minimum of 2 years’ clinical work experience required. + A minimum of 1 year of case management experience in community case management experience highly desired. + This position requires possession and maintenance of a current, valid driver’s license. + 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. We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day. Current Employee apply HERE (https://careers.chenmed.com/i/us/en/homerevisited) Current Contingent Worker please see job aid HERE to apply