- 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.
- 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
- 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.
-
Wound Care Nurse
5 days ago
Regency Nursing and Rehabilitation Center Louisville, United StatesRegency Nursing and Rehabilitation Center - Do you have a passion for geriatrics and desire a rewarding career, excellent benefits, and ample opportunity for advancement? If so, consider joining our nursing team Our facility is comprised of professionals dedicated to maintaining ...
-
Integrated Care Coordinator Nurse
1 week ago
Seven Counties Services Louisville, United StatesJob Description: · ESSENTIAL JOB FUNCTIONS Provides first point of clinic contact for all new clients. Explain services available and focus on engagement of client to access services. · Completes health screenings, nursing assessments and triage healthcare needs for new and on ...
-
Nurse Manager, Critical Care, Days
1 week ago
Norton Healthcare Jeffersonville, United States Full timeResponsibilities · The Nurse Manager is a professional nurse leader who has 24/7 accountability for a patient care area/department and focuses on safe effective patient and family centered care, customer satisfaction and quality outcomes. The Nurse Manager maintains a financiall ...
-
Nurse Manager, Critical Care, Days
6 days ago
Norton Healthcare Jeffersonville, United StatesResponsibilitiesThe Nurse Manager is a professional nurse leader who has 24/7 accountability for a patient care area/department and focuses on safe effective patient and family centered care, customer satisfaction and quality outcomes. The Nurse Manager maintains a financially st ...
-
Nurse Hospital Care
1 week ago
Hosparus Health Louisville, KY, United States Full timeHosparus Health starts with a compassionate team, committed to our mission of creating more moments for our patients facing advanced illness or end of life care. Our premier model of care supports patients and their families with a holistic, team-based approach, wherever the pati ...
-
UofL Health Louisville, United States RegularOverview · University of Louisville Physicians is hiring · Location: · Shift Options: 1st shift · About Us · UofL Health is a fully integrated regional academic health system with seven hospitals, four medical centers, nearly 200 physician practice locations, more than 700 ...
-
Baptist Health System KY & IN Louisville, United States Full timeDescription · : *Sign On Bonus up to $30,000 Available & new revised wage increase* · Critical Care Mixed Acuity Unit · Mixed Acuity Unit is both a critical care and telemetry unit specializing in medical critical care. Staff in this department will receive both critical care ...
-
Primary Care Nurse Practitioner
3 weeks ago
Wayspring Louisville, KY, United StatesResearch shows that while men apply to jobs when they meet an average of 60% of the criteria, women and other marginalized folks tend to only apply when they check every box. So, if you think you have what it takes, but don't necessarily meet every single point on one of our job ...
-
Norton Healthcare Louisville, United States Full time· Responsibilities · The Assistant Nurse Manager is a professional nurse leader who has daily operational responsibility for a patient care area/department and focuses on safe effective patient and family centered care, customer satisfaction and quality outcomes. The Assistant ...
-
RNnetwork Louisville, KY, United StatesRNnetwork is seeking a travel nurse RN CVICU for a travel nursing job in Louisville, Kentucky. · Job Description & Requirements · ~ Specialty: CVICU · ~ Discipline: RN · ~ Start Date: 07/15/2024 · ~ Duration: 13 weeks · ~40 hours per week · ~ Shift: 8 hours · ~ Employment ...
-
Fusion Medical Staffing-Nursing Louisville, KY, United StatesFusion Medical Staffing-Nursing is seeking a travel nurse RN ICU - Intensive Care Unit for a travel nursing job in Louisville, Kentucky. · Specialty: ICU - Intensive Care Unit · ~ Shift: 12 hours, nights · ~ Employment Type: Travel · Facility Details · Facility: Please Conta ...
-
Nursing Assistant Progressive Care Unit
3 weeks ago
Baptist Health New Albany, United StatesJob Description: · Seeking Nursing Assistant · Baptist Health Floyd, Progressive Care Unit · Part-Time (24 Hours/Week), Nights (7pm-7am) · Job Duties: · The Nursing Assistant functions as an on-shift team member under the direction of the nurse by providing delegated aspects of p ...
-
Nursing Assistant Progressive Care Days
3 weeks ago
Baptist Healthcare System, Inc. New Albany, United StatesJob Description: · Seeking Nursing Assistant · Baptist Health Floyd, Progressive Care Unit · Full-Time (36 Hours/Week), Days (7am-7pm) · Job Duties: · The Nursing Assistant functions as an on-shift team member under the direction of the nurse by providing delegated aspects of pat ...
-
Care Team Solutions Louisville, KY, United States TemporaryCare Team Solutions is seeking a travel nurse RN ICU - Intensive Care Unit for a travel nursing job in Louisville, Kentucky. · Specialty: ICU - Intensive Care Unit · ~ Shift: 12 hours · ~ Employment Type: Travel · Must Have 2+ Years of recent Intensive Care Unit experience. ...
-
RNnetwork Louisville, KY, United StatesRNnetwork is seeking a travel nurse RN ICU - Intensive Care Unit for a travel nursing job in Louisville, Kentucky. · Job Description & Requirements · ~ Specialty: ICU - Intensive Care Unit · ~ Discipline: RN · ~ Start Date: 07/15/2024 · ~ Duration: 13 weeks · ~40 hours per w ...
-
Summit Medical Staffing Nursing Louisville, KY, United States TemporarySummit Medical Staffing Nursing is seeking a travel nurse RN ICU - Intensive Care Unit for a travel nursing job in Louisville, Kentucky. · Specialty: ICU - Intensive Care Unit · ~ Shift: 12 hours, nights · ~ Employment Type: Travel · ~ Perks: Up to $500 Travel Reimbursement ( ...
-
Primary Care Family Nurse Practitioner
3 weeks ago
Seven Counties Services Louisville, United StatesJob Description: · ESSENTIAL JOB FUNCTIONS · Provides primary care clinical services to children and adults, including evaluation, follow-up, medication, telephone consultation, etc. Obtains health history and performs physical examinations Performs minor surgical procedures A ...
-
Medical Solutions Louisville, KY, United States26 in non-taxable per diem (amount subject to eligibility & seasonal/annual adjustment) · A facility in Louisville, KY, is currently hiring a RN (Registered Nurse) to work in ICU (Intensive Care Unit). This huge pool of opportunities lets nurses and allied healthcare professional ...
-
ScionHealth - Kindred Cornerstone & Solara Hospitals Louisville, KY, United StatesScionHealth - Kindred Cornerstone & Solara Hospitals is seeking a Registered Nurse (RN) Clinic Wound Care for a nursing job in Louisville, Kentucky. · Job Description & Requirements · Specialty: Wound Care · Discipline: RN · Duration: Ongoing · 36 hours per week · Shift: 12 hours ...
-
HealthTrust Workforce Solution External Louisville, KY, United StatesHealthTrust Workforce Solution External is seeking a travel nurse RN PCU - Progressive Care Unit for a travel nursing job in Louisville, Kentucky. · Job Description & Requirements · ~ Specialty: PCU - Progressive Care Unit · ~ Discipline: RN · ~ Start Date: 07/29/2024 · ~ Dur ...
Community Care Nurse - Louisville, United States - ChenMed
Description
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 team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home.The Register Nurse (RN) Community Care Nurse will serve as a clinical lead for a Community Care team. They will 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 initial assessments and design comprehensive plans of care for many of these patients. 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.
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:
Coordinate the Plan of Care:
KNOWLEDGE, SKILLS AND ABILITIES:
EDUCATION AND EXPERIENCE CRITERIA:
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
Current Contingent Worker please see job aid HERE to apply
Community Care Nurse professionals in Louisville
-
Kara Hockenbury
Utilization Management Clinician
-
Ava Amin
Pre-law student