Acute Care Case Manager (RN) - Complex Care Navigator

chenmed; Evergreen Park (IL); On-site; USD 90,000 - 130,000; Full time

Job summary

ChenMed is seeking an Acute Care Manager, Complex Care (RN) to lead hospital-based care coordination for high-risk patients. You will shepherd patients from admission through discharge, collaborating with hospitalists, PCPs, and community care teams to ensure safe transitions and timely follow-up.

This role emphasizes post-acute planning, SDoH considerations, and ongoing communication with families and care teams to deliver high-quality, longitudinal care.

Responsibilities

• Daily presence of team at hospitals during core hours and balanced caseload.
• Identify opportunities for proper resource allocation; assess inpatient vs observation.
• Assess safety risks, ADLs, medications, self-management, and knowledge gaps.
• Collaborate with Complex Care and Clinical Strategy to follow SOPs.
• Explain the Care Management/Disease Management program to families and arrange home visit after discharge.
• Implement ACM Coaching for eligible patients.
• Identify barriers to safe discharge from hospital stay.
• Consult ChenMed specialists to support patient care in facilities.
• Coordinate transition to lower level of care with SNF/post-acute teams.
• Facilitate discharge to appropriate level and providers.
• Communicate discharge to patient, family, PCP, and care team.
• Document discharge date and updates in chart.
• Perform SDoH screening on admission and alert Community Social Workers if needed.
• Identify new diagnoses and share documentation with PCPs for updates.
• Arrange 4-day follow-up PCP appointment prior to discharge.

Job description

ChenMed is seeking an Acute Care Manager, Complex Care (RN) to lead hospital-based care coordination for high-risk patients. You will shepherd patients from admission through discharge, collaborating with hospitalists, PCPs, and community care teams to ensure safe transitions and timely follow-up.

This role emphasizes post-acute planning, SDoH considerations, and ongoing communication with families and care teams to deliver high-quality, longitudinal care.