RN, Care Coordinator

Chapters Health System•Tavares, FL

10d•$61,861 - $96,657

About The Position

The RN, Care Coordinator (described in the profile as RN, Case Manager) 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 plans as needs evolve, and educates patients, families, caregivers, and health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety. The position involves patient visits, including home assessments of safety, medication and nutritional compliance, durable medical equipment compliance, and the ability to live safely in the community. Visit frequency is determined by participant risk score and needs. The RN communicates patient changes and clinical information to the IDT and physicians, participates in daily IDT collaboration meetings, and may supervise care provided by Community Health Workers and Home Health Aides when requested. 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. The role also includes providing phone reassurance and coordinating in-person visits at some locations, completing initial and semi-annual assessments for Company services, and representing the Company at assigned facilities while facilitating referrals. Employees must comply with applicable regulations and Company policies, maintain confidentiality, use resources responsibly, participate in quality improvement and other organizational activities, and maintain professional knowledge and skills. Employment is conditional on consent to drug and/or alcohol testing after a conditional offer and, for Florida affiliate services, ongoing eligibility verification through the Florida Care Provider Background Screening Clearinghouse.

Requirements

Current RN license in the state where the employee will work.
Minimum of one year of nursing experience; hospice or hospital experience is preferred.
Previous experience working with an EMR/EHR system.
Valid driver’s license and automobile insurance according to 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, with or without reasonable accommodation, including lifting patients and/or equipment, bending, pushing/pulling, and kneeling.
Active BLS for healthcare professionals from the American Heart Association or Red Cross.
Satisfactorily complete competency requirements for the position.
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 nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Coordinate the Plan of Care with the IDT and ensure it is individualized and reflects the patient’s evolving needs.
Provide and manage direct care to patients and families, incorporating psychosocial, spiritual, cultural, physical, and biological components and appropriate nursing interventions and follow-up.
Educate patients, families, caregivers, and health professionals about disease process and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety, medication compliance, nutritional compliance, DME compliance, and ability to live safely in the community; determine visit frequency based on risk score and needs.
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 and attend daily IDT collaboration meetings.
Present concise and pertinent oral and written reports to the IDT, respecting and encouraging 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 when requested.
At some locations, reassure patients and families by phone, help resolve questions, identify when an in-person visit is needed, and coordinate visits when needed or requested.
Use appropriate support, expert resources, or personnel to resolve complex or difficult situations.
Document patient and family contact information in the EMR and communicate it to the IDT.
Complete initial and semi-annual assessments for Company services.
Explain services to patients and families, address questions about needs, fears, and physical limitations, and present services empathetically and compassionately.
Provide information to physicians and other IDT members and initiate a Plan 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, discuss potential needs with after-hours staff, and develop relationships with facility case managers and physicians.
Represent the Company professionally; comply with regulations, policies, safety practices, and confidentiality requirements; and use resources responsibly.
Participate in community and professional organizations, organizational performance improvement, professional learning, electronic media skill development, research and educational activities, knowledge sharing, and Quality Assessment and Performance Improvement activities as appropriate.
During emergencies, report to a company-designated location as required, potentially ahead of scheduled time and overnight, to ensure continuity of services.
Perform other duties as assigned.