RN Field Case Manager -Mon - Friday

Chapters Health System•Auburndale, FL

5d•$61,861 - $96,657

About The Position

The RN, Case Manager assesses and identifies patient and family needs, uses the nursing process, and coordinates the Plan of Care with the Interdisciplinary Team (IDT). The role provides clinical, palliative, and supportive care to patients and families to help participants remain in their home environment as long as possible. The position includes home visits, patient and family education, clinical documentation, coordination with physicians and other IDT members, and representation of the Company at assigned facilities. The schedule is Monday through Friday. During emergencies, the RN may be required to work at a Company-designated location, including reporting earlier than scheduled or staying overnight to maintain continuity of services. The RN provides and manages direct care incorporating psychosocial, spiritual, cultural, physical, and biological needs; coordinates an individualized Plan of Care as needs evolve; and communicates patient changes and care information to the IDT and other health professionals. Home visits may assess safety, medication and nutritional compliance, durable medical equipment compliance, and the patient's ability to live safely in the community. Visit frequency depends on risk score and needs. The RN also participates in daily IDT collaboration meetings, evaluates hospice referrals and admissions for appropriate level of care, and may supervise care delivered by Community Health Workers and Home Health Aides when requested.

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.
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 the essential job functions and physical requirements, with or without reasonable accommodation.
Active BLS for healthcare professionals certification from the American Heart Association or Red Cross.
Satisfactorily complete competency requirements for the position.

Nice To Haves

Hospice or hospital nursing 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

Assess and identify patient and family needs using the nursing process.
Coordinate the Plan of Care with the IDT and ensure it reflects the patient's evolving needs.
Provide and manage direct patient and family care, including 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, durable medical equipment compliance, and 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 encourage input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors, including timely clinical communication using SBAR.
Supervise patient care provided by Community Health Workers and Home Health Aides when requested.
Provide phone reassurance to patients and families, help address questions, and coordinate in-person visits when needed or requested, where applicable to the location.
Use appropriate support resources or personnel to resolve complex situations, where applicable to the location.
Document patient and family contact information in the EMR and communicate with the IDT.
Complete initial and semi-annual assessments for Company services, where applicable to the location.
Explain services to patients and families, address questions and concerns, and present services empathetically and compassionately, where applicable to the location.
Provide information to physicians and IDT members and initiate the Plan of Care to address immediate needs, where applicable to the location.
Initiate skilled nursing interventions to support prevention, prevent complications, alleviate symptoms, and maximize physical and emotional comfort, where applicable to the location.
Obtain physician orders and complete documentation according to Company policy, where applicable to the location.
Represent the Company at assigned facilities and facilitate referrals to service lines; work with referring hospitals, physicians, facilities, patients, families, and the public, where applicable to the location.
Communicate frequently with IDT members, discuss potential needs with after-hours staff, and build relationships with facility case managers and physicians.
During emergencies, report to a Company-designated location as required to ensure continuity of services, which may include early reporting or overnight stays.
Perform other duties as assigned.
Represent the Company professionally; comply with applicable regulations, policies, procedures, and safety and security practices; maintain confidentiality; and use resources responsibly.
Participate in community and professional organizations, performance improvement, professional learning, electronic media skill development, Company research and educational activities, knowledge-sharing, and Quality Assessment and Performance Improvement activities as appropriate.