RN, Care Coordinator

Chapters Health•Tavares, FL

About The Position

The RN, Care Coordinator assesses and identifies patient and family needs, uses the nursing process, coordinates the Plan of Care with the Interdisciplinary Team (IDT), and provides clinical, palliative, and supportive care to help participants remain in their home environment as long as possible. The role provides and manages direct patient and family care, coordinates individualized and evolving Plans of Care, educates patients, families, caregivers, and other health professionals, and reports changes in patient condition to the appropriate people. Home visits assess safety and the participant’s ability to live safely in the community, including medication, nutrition, and durable medical equipment compliance. Visit frequency depends on risk score and needs. The RN communicates with patients and families, physicians, facilities, and IDT members; participates in IDT collaboration and referral/admission evaluations; documents care and communications; and may supervise care provided by Community Health Workers and Home Health Aides. During emergencies, the position may require reporting to a company-designated location ahead of schedule and staying overnight to maintain continuity of services. The role also includes general employee responsibilities such as following regulations and company policies, protecting confidentiality, using resources responsibly, and participating in quality improvement and professional development activities.

Requirements

Current RN license in the state where the employee will work.
At least one year of nursing experience; hospice or hospital experience is preferred.
For employees working at PACE, completion certification for Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs.
Previous experience with 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, with or without reasonable accommodation, including lifting patients and/or equipment, bending, pushing, pulling, and kneeling.
Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.
Ability to complete the competency requirements for the position.
Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
Eligibility verification through the Florida Care Provider Background Screening Clearinghouse for employees performing services for Florida affiliates.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Provide and manage direct care to patients and families as part of the Interdisciplinary Team, incorporating psychosocial, spiritual, cultural, physical, and biological considerations and appropriate nursing interventions and follow-up.
Coordinate the Plan of Care and ensure it is individualized and reflects the patient’s changing needs.
Educate patients, families, caregivers, and health professionals about disease processes and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety and medication, nutritional, and DME compliance, including the participant’s ability to live safely in the community.
Report changes in patient condition to appropriate IDT members and other health professionals.
Participate with the IDT 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 respect and encourage input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors, using positive approaches.
Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
Provide reassurance and assistance to patients and families by phone, identify when an in-person visit is needed, coordinate visits, and use appropriate support resources to resolve complex situations.
Document patient and family contacts in the EMR and communicate with the IDT.
Complete initial and semi-annual assessments for company services; explain services, address questions and concerns empathetically, provide information to physicians and IDT members, initiate Plans of Care and skilled nursing interventions, obtain physician orders, and complete documentation under company policy.
Represent the company at assigned facilities, facilitate referrals to service lines, and build relationships with case managers, physicians, and other facility contacts.
Communicate clinical information to the IDT in a timely manner using SBAR and discuss potential needs with after-hours staff.
During emergencies, report to a company-designated location as needed, potentially ahead of the scheduled time and with overnight stays.
Represent the company professionally; comply with applicable laws, regulations, policies, and practices; maintain confidentiality; use resources responsibly; participate in community, professional, quality improvement, research, and educational activities; and continue developing professional and electronic media skills.
Perform other duties as assigned.