RN, Care Coordinator Mon-Thurs 4 10s with sign on bonus and charter school eligible

Chapters Health•The Villages, FL

About The Position

The 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 while addressing psychosocial, spiritual, cultural, physical, and biological needs. The position includes assessing patients, explaining services, initiating and coordinating individualized Plans of Care, providing skilled nursing interventions, obtaining physician orders, educating patients and caregivers, and documenting care according to company policy. The RN communicates patient needs and changes to the IDT and other health professionals, participates in daily IDT collaboration meetings, and may represent the company at assigned facilities and support referrals. Home visits assess safety and compliance with medication, nutrition, and durable medical equipment needs. Visit frequency is based on participant risk and needs. The schedule indicated in the posting title is Monday through Thursday, four 10-hour shifts. During emergencies, such as hurricanes, the RN may be required to report to a company-designated location ahead of schedule and stay overnight as needed to maintain services. The position requires consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy. Florida affiliate employees are subject to background screening and ongoing eligibility verification through the Florida Care Provider Background Screening Clearinghouse.

Requirements

Current registered nurse (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 using 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 the essential job functions and physical requirements, including lifting patients and/or equipment, bending, pushing, pulling, and kneeling, with or without reasonable accommodation.
Active BLS certification for healthcare professionals from the American Heart Association or the Red Cross.
Satisfactory completion of the position’s competency requirements.
Ability to meet the physical demands of the role, including seeing, hearing, talking, walking, and using hands to finger, handle, or feel; frequently standing, sitting, reaching, lifting, bending, and balancing; and occasionally pulling, pushing, stooping or crouching, kneeling, and climbing stairs.
Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
For services performed for Florida affiliates, eligibility for background screening and continued verification through the Florida Care Provider Background Screening Clearinghouse.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Provide and manage direct care to patients and families as part of the Interdisciplinary Team, incorporating appropriate nursing interventions and follow-up.
Coordinate an individualized Plan of Care that reflects the patient’s evolving needs.
Educate patients, families, caregivers, and other health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety and compliance with medication, nutritional, and durable medical equipment needs, including the participant’s ability to live safely in the community.
Provide reassurance and support to patients and families by phone, identify when an in-person visit is needed, and coordinate visits as appropriate.
Complete initial and semi-annual assessments for company services; explain services and address patient and family questions and concerns empathetically.
Initiate skilled nursing interventions to prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation according to company policy.
Communicate changes in patient condition and clinical information promptly and accurately to the IDT, physicians, staff, patients, families, and supervisors, using SBAR as appropriate.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness; attend daily IDT collaboration meetings and present concise reports while encouraging input from all disciplines.
Act as the company representative at assigned facilities, facilitate referrals to service lines, and maintain relationships with case managers, physicians, hospitals, facilities, patients, families, and the public.
Coordinate with after-hours staff regarding potential needs and use support resources or personnel to resolve complex situations.
Supervise care provided by Community Health Workers and Home Health Aides as requested.
During emergencies, report to a company-designated location as required, potentially ahead of the scheduled work time and with overnight stays.
Represent the company professionally; comply with applicable regulations and company policies; maintain confidentiality; use resources responsibly; and observe health, safety, and security practices.
Participate in performance improvement, quality assessment, community and professional organizations, and company research and educational activities as appropriate; maintain professional knowledge and electronic media skills and share expertise with coworkers.
Perform other duties as assigned.