Intensive Community Care RN Lead

ChenMed LLC; Portsmouth (NH); On-site; USD 51,000 - 73,000; Full time

Job summary

ChenMed is seeking an Intensive Community Care Manager (RN) to lead complex case management for high-risk patients. You will coordinate care plans with PCPs, conduct home visits, and provide clinical supervision to team members in the Complex Care Team.

The role emphasizes preventing hospitalizations and supporting patient self-management. Responsibilities include performing health assessments, coordinating services, and guiding care transitions in home and facility settings, while ensuring

Qualifications

• RN license in state of employment (active).
• Associate degree in nursing required; BSN preferred.
• Minimum 2 years clinical experience; case management experience desired.

Responsibilities

• Provides in-house, facility, and telephonic visits to high-risk patients to prevent hospital admissions.
• Conducts home visits to assess, plan, and adjust care plans.
• Supervises LPNs and other staff; delivers education and discharge planning.
• Performs SDoH, disease management, and medication monitoring assessments.
• Coordinates initial case management assessment and plans of care with PCPs and care teams.
• Maintains ongoing communication with families and community providers; supports patient self-management.
• Collaborates with Complex Care Leadership and Hospital Care Managers to ensure holistic care.

Skills

Interpersonal skills

Critical thinking

Autonomous work

Care plan development

Nursing knowledge

Documentation

Community resources navigation

Team coordination

Communication of technical info

Travel up to 10%

Education

Associate degree in Nursing

BSN preferred or RN with bachelor’s degree

Tools

Microsoft Office Suite

Job description

ChenMed is seeking an Intensive Community Care Manager (RN) to lead complex case management for high-risk patients. You will coordinate care plans with PCPs, conduct home visits, and provide clinical supervision to team members in the Complex Care Team.

The role emphasizes preventing hospitalizations and supporting patient self-management. Responsibilities include performing health assessments, coordinating services, and guiding care transitions in home and facility settings, while ensuring