RN Care Coordinator LifePath Hospice

Chapters Health System•Sun City Center, FL

23h•Onsite

About The Position

It’s inspiring to work with a company where people truly BELIEVE in what they’re doing! When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success! 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.

Requirements

Current license as RN in the state where the employee will be working
Minimum of 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)
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
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

Responsibilities

Provide and manage direct care to patients and families as part of the Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
Coordinate the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
Educate patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices.
Conduct home visits to assess home safety, medication compliance, nutritional compliance, and DME compliance to ensure ability to live safely in the community.
Report changes in the patient’s condition to appropriate members of the IDT or other health professionals.
Participate with the IDT to evaluate hospice referrals/admissions for level of care appropriateness and attend daily IDT collaboration meetings.
Present concise and pertinent oral and written reports to IDT, respecting and encouraging input from all disciplines.
Communicate accurately and completely to physicians, staff members, patients, families, and supervisors, utilizing positive approaches.
Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
Be available to report to a designated company location during times of emergencies (e.g., Hurricanes) to ensure continuity of services, potentially staying overnight.
Provide reassurance on the phone to patients and families and assist in finding solutions to their questions or recognizing the need for an in-person visit.
Coordinate in-person visits when needed or requested.
Utilize appropriate support/expert resources or personnel to resolve complex or difficult situations.
Document patient/family contact information in the EMR and communicate with the Interdisciplinary Team (IDT).
Complete initial and semi-annual assessments for all Company services, explaining services to patients/families empathetically.
Provide information to Physicians and other IDT members and initiate Plan of Care to address patient’s immediate needs.
Initiate skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort.
Obtain Physician orders and complete documentation per Company policy.
Act as the Company representative at assigned facilities, facilitating referrals to all service lines and working closely with referring hospitals, physicians, facilities, patients, families, and the general public.
Communicate frequently with other members of the IDT, providing all necessary clinical communication timely using SBAR.
Discuss any potential needs with after-hours staff.
Develop strong relationships with case managers, physicians, etc. at facilities.
Represent the Company professionally at all times through care delivered and/or services provided to all clients.
Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
Comply with Company policies, procedures and standard practices.
Observe the Company's health, safety and security practices.
Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
Use resources in a fiscally responsible manner.
Promote the Company through participation in community and professional organizations.
Participate proactively in improving performance at the organizational, departmental and individual levels.
Improve own 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 for the position.