RN, Care Coordinator M-TH

Chapters Health System•Ocala, FL

1d•Hybrid

About The Position

The RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative and supportive care to the patient/family unit in order to keep the participant in their home environment as long as possible. Chapters Health System is a progressive leader and premier health organization, dedicated to delivering innovative care throughout chronic illness progression and beyond. Since 1983 as a community-based, not-for-profit organization, Chapters Health has provided choices, education and guidance through its managed affiliates. Chapters Health offers services throughout the Southeast and Mid-Atlantic regions of the country to improve the patient/family experience well in advance of end-of-life needs.

Requirements

Current license as RN in the state where the employee will be working
Minimum of one (1) year nursing experience; hospice or hospital experience preferred
Employees working at PACE, certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs
Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
Mobile Driver - 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)
Ability to visit Participant in their homes to assessments
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
Active BLS for healthcare professionals from the American Heart Association or Red Cross.

Nice To Haves

hospice or hospital experience preferred

Responsibilities

Provides and manages direct care to patients and families as part of Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
Educates patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices.
Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance- ability to live safely in the community.
Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals.
Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.
Attends daily IDT collaboration meetings.
Presents concise and pertinent oral and written reports to IDT; respects and encourages input from all disciplines.
Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others.
Supervises patient care provided by Community Health Workers and Home Health Aides as requested.
During times of emergencies (i.e. Hurricanes, etc.), the RN, Case Manager may be required to report to work at a location designated by the company, to ensure continuity of services. This may include reporting to work ahead of your scheduled date/time due to planned lock down of unit, and staying overnight(s) based on duration of emergency.
Performs other duties as assigned.
Provides reassurance on the phone to patients and families.
Assists in finding solutions to their questions and/or recognizes the need for an in person visit.
Coordinates in person visit when needed/or requested.
Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations.
Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT).
Completes initial and semi-annual assessment for all Company services including, but not limited to:
Explains services to patients/families and addresses questions regarding patient needs, fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner.
Provides information to Physicians and other IDT members and initiates Plan of Care to address patient’s immediate needs.
Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort.
Obtains Physician orders.
Completes documentation per Company policy.
Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public.
Communicates frequently with other members of the IDT.
Provides all necessary clinical communication timely using SBAR.
Discusses any potential needs with after-hours staff.
Develops strong relationships with case managers, physicians, etc. at facilities.