Per Diem- PACE RN, Case Manager-PACE Program

Chapters Health System•Naples, FL

17h•Onsite

About The Position

The Per Diem RN, Case Manager for the PACE Program is responsible for assessing patient/family needs, coordinating care with the Interdisciplinary Group (IDG), and providing palliative and supportive care. This role involves comprehensive clinical admissions, acting as a company representative at various facilities, facilitating referrals, and ensuring timely communication with all stakeholders. The position requires adherence to professional standards, compliance with regulations, maintaining confidentiality, and continuous professional development. It also includes providing direct patient care, educating families, supervising other nursing staff, and responding to emergencies.

Requirements

Current license as RN in the state where the employee will be working
Active BLS for healthcare professionals from the American Heart Association or Red Cross.
Minimum one (1) year nursing experience
Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
Valid driver’s license and automobile insurance per Company policy
Reliable transportation to meet visit schedule
Ability to use equipment with visual and auditory mechanisms
Ability to effectively communicate in English (verbal and written)
Flexible schedule to meet the needs of Hospice House patients
Ability to manage the emotional stress of working with and caring for terminally ill patients and their families
Ability to physically access patient rooms, other areas of the Hospice House/Hospital/ALF, etc., and any home (i.e., navigate stairs and narrow spaces, tolerate heat and lack of air conditioning) within any part of the service area
Ability to perform the essential functions and physical requirements (including, but not limited to: lifting patients and/or equipment, bending, pushing/pulling, kneeling) of the job with or without reasonable accommodation
For employees working at PACE, certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.

Nice To Haves

Hospice or hospital experience preferred
Cross training to hospice house or field (home/facility/admission) positions of equal licensure/certification and scope when census calls for flexible staffing

Responsibilities

Assess and identify patient/family needs, utilizing the nursing process.
Coordinate the Plan of Care with the Interdisciplinary Group (IDG) to reflect evolving patient needs.
Provide palliative and supportive care to the patient/family unit, incorporating psychosocial, spiritual, cultural, physical, and biological components.
Educate patients, families, caregivers, and other health professionals on disease progression, palliative interventions, caregiving, dying process, and safety practices.
Report changes in patient condition to appropriate IDG members or other health professionals.
Participate with the IDG in evaluating hospice referrals/admissions for level of care appropriateness.
Attend patient deaths, prepare the body for transport, and oversee medication disposal.
Provide appropriate bereavement interventions to families and caregivers in conjunction with psychosocial staff.
Present concise and pertinent oral and written reports to the IDG, encouraging input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors.
Supervise patient care provided by other nursing team members (LPNs, Hospice Aides, contract nurses).
Be available to report to a designated company location and potentially stay overnight during emergencies (e.g., Hurricanes) to ensure service continuity.
Perform other duties as assigned.
Complete clinical admissions for all Company services, including explaining services, addressing concerns, educating on requirements, obtaining consents, performing initial assessments, initiating Plan of Care, and providing skilled nursing interventions.
Obtain Physician orders and complete documentation according to Company policy.
Act as the Company representative at assigned facilities, facilitating referrals and working closely with referring hospitals, physicians, facilities, patients, families, and the general public.
Communicate frequently with Admissions for timely follow-up and prepare for subsequent assignments.
Provide timely clinical communication using SBAR and discuss potential needs with after-hours staff.
Obtain consents for services and arrange safe, efficient discharges for eligible patients, meeting productivity expectations.
Obtain medical record information for referrals.
Develop strong relationships with case managers and physicians at facilities.
Collaborate with Professional Relations Representatives (PRRs) to educate on available services.
Provide care for any GIP patients in a hospital, including daily visits, professional management, documentation, and efficient discharge.
Represent the Company professionally, comply with all State, federal, and local government regulations, Company policies, procedures, and standard practices, and observe health, safety, and security practices.
Maintain the confidentiality of patients, families, colleagues, and other sensitive situations.
Use resources in a fiscally responsible manner and promote the Company through community and professional organizations.
Participate proactively in improving performance at organizational, departmental, and individual levels, improve professional knowledge and skill level, and advance electronic media skills.
Support Company research and educational activities and share expertise with co-workers.
Participate in Quality Assessment and Performance Improvement activities as appropriate.