RN, Care Coordinator

Chapters Health System•Tavares, FL

110d•$61,861 - $96,657

About The Position

The RN, Case Manager assesses and identifies patient and family needs using 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 includes direct patient and family care, assessment of evolving needs, education, clinical communication, coordination with physicians and other professionals, and follow-up. Home visits may include assessment of home safety, medication and nutritional compliance, durable medical equipment compliance, and the participant’s ability to live safely in the community. Visit frequency depends on risk score and needs. The nurse may provide telephone reassurance and assistance to patients and families, arrange in-person visits when needed, use appropriate expert resources to address complex situations, document contacts in the EMR, and communicate with the IDT. The role may also involve representing the company at assigned facilities, facilitating referrals, and developing relationships with case managers, physicians, and other facility contacts. During emergencies, the employee may be required to report to a company-designated location ahead of schedule and stay overnight as needed to maintain continuity of services.

Requirements

Current Registered Nurse license in the state where the employee will work.
At least one year of nursing experience.
Previous experience working 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 for 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 Basic Life Support certification for healthcare professionals from the American Heart Association or Red Cross.
Satisfactory completion of 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.
For employees performing services for Florida affiliates, eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and ongoing eligibility.

Nice To Haves

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.

Responsibilities

Provide and manage direct care to patients and families as part of the Interdisciplinary Team, incorporating psychosocial, spiritual, cultural, physical, and biological needs and appropriate nursing interventions and follow-up.
Coordinate the Plan of Care and ensure it is individualized and reflects the patient’s evolving needs.
Educate patients, families, caregivers, and other health professionals about disease processes and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct participant visits at a frequency determined by risk score and needs.
Make home visits to assess home safety, medication compliance, nutritional compliance, durable medical equipment compliance, and ability to live safely in the community.
Report changes in patient condition to appropriate IDT members or other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness.
Attend daily IDT collaboration meetings.
Present concise and pertinent oral and written reports to the IDT and encourage input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors, using positive approaches when working with others.
Supervise patient care provided by Community Health Workers and Home Health Aides when requested.
Provide telephone reassurance to patients and families, help resolve questions, and recognize when an in-person visit is needed; coordinate visits when needed or requested.
Use appropriate support or expert resources to resolve complex or difficult situations.
Document patient and family contact information in the EMR and communicate with the IDT.
Complete initial and semi-annual assessments for company services.
Explain services to patients and families, address questions and concerns, and present services empathetically and compassionately.
Provide information to physicians and other IDT members and initiate Plans of Care to address immediate patient needs.
Initiate skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation according to company policy.
Represent the company at assigned facilities and facilitate referrals to service lines; work with referring hospitals, physicians, facilities, patients, families, and the public.
Communicate frequently with IDT members, provide timely clinical communication using SBAR, and discuss potential needs with after-hours staff.
Develop relationships with case managers, physicians, and other facility contacts.
During emergencies, report to a company-designated work location as required, potentially ahead of scheduled hours and including overnight stays.
Perform other duties as assigned.
Represent the company professionally and comply with applicable regulations, policies, procedures, health and safety practices, confidentiality requirements, and responsible resource use.
Participate in community and professional organizations, performance improvement, professional development, electronic media skills development, research and educational activities, knowledge sharing, and Quality Assessment and Performance Improvement activities as appropriate.