RN, Case Manager-Hope Hospice-Patient Homes

Chapters Health System•Cape Coral, FL

12d•$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 patients remain in their home environment as long as possible. The role provides and manages direct patient and family care, develops individualized plans that reflect changing needs, and educates patients, families, caregivers, and health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices. The case manager conducts home visits and assessments, communicates patient changes and care needs to the IDT and physicians, participates in referral and admission evaluations, and supervises care provided by Community Health Workers and Home Health Aides when requested. The position involves five eight-hour shifts and every other weekend. During emergencies, employees may be required to report to a company-designated location ahead of schedule and may need to stay overnight to maintain continuity of services.

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 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 essential job functions and physical requirements, with or without reasonable accommodation, including lifting patients and/or equipment, bending, pushing and pulling, and kneeling.
Active BLS for healthcare professionals certification from the American Heart Association or Red Cross.
For employees working at PACE: completion certification for Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs.
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 verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and ongoing eligibility.

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 (IDT), incorporating psychosocial, spiritual, cultural, physical, and biological components 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 process and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety, medication and nutritional compliance, durable medical equipment 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 and other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness.
Attend daily IDT collaboration meetings and present concise, pertinent oral and written reports while respecting and encouraging input from all disciplines.
Communicate accurately and completely with physicians, staff members, patients, families, and supervisors; use positive approaches when working with others.
Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
Provide reassurance and help to patients and families by phone, identify when an in-person visit is needed, and coordinate visits when needed or requested.
Use appropriate support resources or personnel to resolve complex situations; document patient and family contacts in the EMR and communicate with the IDT.
Complete initial and semi-annual assessments for Company services; explain services, address questions and concerns empathetically, provide information to physicians and IDT members, initiate Plans of Care and skilled nursing interventions, obtain physician orders, and complete documentation according to Company policy.
Represent the Company at assigned facilities, facilitate referrals to service lines, and develop relationships with case managers, physicians, and other facility contacts.
Communicate clinical information promptly using SBAR and discuss potential needs with after-hours staff.
During emergencies, report to a company-designated location as required, which may involve reporting ahead of schedule and staying overnight.
Represent the Company professionally; comply with applicable regulations and Company policies; observe health, safety, and security practices; maintain confidentiality; and use resources responsibly.
Promote the Company through community and professional organizations; participate in performance improvement, quality assessment, research, and educational activities; maintain professional knowledge and skills; advance electronic media skills; and share expertise with coworkers.
Complete the competency requirements for the position and perform other duties as assigned.