Field RN Case Manager/Sun-Wed Cornerstone Hospice

Chapters Health•Orlando, FL

10d

About The Position

The RN, Care Coordinator provides palliative and supportive care to patients and families, assesses and identifies their needs using the nursing process, and coordinates an individualized Plan of Care with the Interdisciplinary Team (IDT). The role includes direct patient and family care, ongoing assessment, education, follow-up, and communication with physicians, colleagues, facilities, and other professionals. Home visits assess safety and compliance with medication, nutrition, and durable medical equipment needs, as well as the patient’s ability to live safely in the community. Visit frequency is determined by risk score and needs. The position works closely with the IDT to evaluate hospice referrals and admissions, attend daily collaboration meetings, and communicate clinical updates using SBAR. The RN may represent the company at assigned facilities and develop relationships with case managers, physicians, hospitals, patients, families, and the public. During emergencies, the RN may need to report to a company-designated location ahead of schedule and stay overnight to maintain continuity of services. Employees are expected to represent the company professionally, comply with applicable laws and company policies, protect confidentiality, use resources responsibly, maintain and improve professional skills, and participate in quality improvement and other organizational activities. The position also requires consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy. Florida affiliate employees are subject to background screening and ongoing eligibility verification through the Florida Care Provider Background Screening Clearinghouse.

Requirements

Current registered nurse license in the state where the employee will work.
Previous experience using an EMR/EHR system.
Valid driver's license and automobile insurance in accordance with company policy.
Reliable transportation to meet the visit schedule.
Ability to use equipment with visual and auditory mechanisms.
Ability to communicate effectively in English, verbally and in writing.
Ability to visit participants in their homes to conduct assessments.
Ability to perform essential job functions and physical requirements, including lifting patients and/or equipment, bending, pushing/pulling, and kneeling, with or without reasonable accommodation.
Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.
Satisfactorily complete the competency requirements for the position.

Nice To Haves

At least one year of nursing experience; hospice or hospital experience is preferred.
For employees working at PACE: certificate of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.

Responsibilities

Assess patient and family needs and coordinate an individualized Plan of Care with the Interdisciplinary Team.
Provide and manage direct patient and family care, including appropriate nursing interventions and follow-up that address psychosocial, spiritual, cultural, physical, and biological needs.
Provide reassurance and support by phone, help resolve questions, determine when an in-person visit is needed, and coordinate visits when appropriate.
Complete initial and semi-annual assessments for applicable company services; explain services and address patient and family questions and concerns empathetically.
Initiate skilled nursing interventions to prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation in accordance with company policy.
Educate patients, families, caregivers, and health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety, medication, nutrition and DME compliance, and the patient's ability to live safely in the community; determine visit frequency based on risk score and needs.
Report changes in patient condition to appropriate IDT members and other health professionals; provide timely, accurate clinical communication, including SBAR reports.
Participate in evaluating hospice referrals and admissions for level-of-care appropriateness and attend daily IDT collaboration meetings.
Present concise oral and written reports to the IDT and encourage input from all disciplines.
Act as the company representative at assigned facilities, facilitate referrals across service lines, and develop relationships with referring hospitals, physicians, facilities, case managers, patients, families, and the public.
Communicate with after-hours staff about potential needs and document patient and family contacts in the EMR.
Supervise care provided by Community Health Workers and Home Health Aides when requested.
During emergencies, report to a company-designated location as required, potentially ahead of schedule and with overnight stays, to ensure continuity of services.
Comply with applicable regulations, company policies, health and safety practices, and confidentiality requirements; use resources responsibly.
Participate in community and professional organizations, performance improvement, company research and educational activities, and ongoing professional development; share expertise and advance electronic media skills.
Perform other duties as assigned.