Intensive Community Manager, Complex Care (RN)
Core
Advocate for patients and manage quality of care across the continuum, coordinating transitions between acute, post-acute, and home environments.
Role type
Senior Registered Nurse Case Manager (Complex Care)
Builds
Effective care plans and high levels of care coordination for patients with complex needs
Domain
Healthcare / Complex Care Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Care coordination, discharge planning, psychosocial assessment, resource utilization management, patient advocacy, clinical documentation, stakeholder collaboration
Preferred skills
Experience with high-volume/high-priority hospital transitions, disease management programs, telephonic/outpatient visit management
Technologies
EMR systems, DASH, HITS
Responsibilities
Manage transitions of care and discharge planning; establish trusting relationships with patients and caregivers; collaborate on plan of care development; coordinate social services and referrals; conduct psychosocial assessments; maintain clinical progress notes; facilitate patient/family conferences; address advanced care planning; report suspected abuse; promote efficient clinical resource utilization.
Seniority
Senior, hands-on IC