Community Care Nurse, RN at ChenMed

Unclassified - Tampa, FL

Full-time - Mid Level

Tampa, FL

About the position

DirectEmployers is seeking a Registered Nurse (RN) Community Care Nurse to join our rapidly expanding Community Care team in Tampa, FL. This unique position is designed for innovative and entrepreneurial-minded individuals who are passionate about making a difference in the lives of our patients. As a clinical lead for the Community Care team, the RN will coordinate efforts to stabilize our highest risk patients, focusing on safe transitions of care from facilities back to primary care teams, and outreach to patients who are not currently engaged in care. The RN will perform initial assessments and design comprehensive care plans, providing clinical supervision to other team members to ensure effective delivery of care. This role requires adherence to departmental goals, regulatory compliance, and quality patient care standards. The RN Community Care Nurse will conduct in-home and telephonic visits to patients at high risk for hospital admissions and readmissions, aiming to prevent such occurrences. Responsibilities include performing initial assessments, developing care plans for Licensed Practical Nurses (LPNs), conducting supervisory visits, and providing education to patients. The RN will also assess social determinants of health, coordinate multidisciplinary team meetings, and help patients navigate healthcare systems while connecting them with community resources. Establishing supportive relationships with patients and monitoring the quality of care provided are essential aspects of this role. The RN will also assist patients and families in accessing community and financial resources, ensuring a holistic approach to patient care.

Responsibilities

• Provide in-home and telephonic visits to high-risk patients to prevent hospital admissions and readmissions.
• Conduct initial assessments and develop care plans for Licensed Practical Nurses (LPNs).
• Perform supervisory visits with LPNs to provide education and oversee patient discharge from case management.
• Conduct clinical and social determination of health assessments, including medication monitoring and health education.
• Coordinate the Plan of Care, ensuring it reflects patient needs and available community services.
• Communicate instructions and methodologies to ensure proper implementation of care plans.
• Assess the environment of care, caregiver capacity, and educational needs of patients and caregivers.
• Coordinate and document multidisciplinary team meetings and follow-ups.
• Help patients navigate healthcare systems and connect them with community resources.
• Establish supportive relationships with patients to promote self-management and well-being.

Requirements

• Associate degree in Nursing required; Bachelor's Degree in Nursing (BSN) preferred.
• Valid, active Registered Nurse (RN) license in the state of employment required.
• Minimum of 2 years' clinical work experience required.
• Strong interpersonal and communication skills to work effectively with diverse communities.
• Critical thinking skills and ability to work autonomously.
• Ability to monitor, assess, and record patients' progress and adjust care plans accordingly.
• Knowledge of nursing and case management theory and practice.
• Proficient in Microsoft Office Suite and various software applications.

Nice-to-haves

• Bilingual skills are a plus.
• Experience in community health services and social services support agencies.