RN, Case Manager (Pinellas County) Monday - Friday

Chapters Health System•Largo, FL

5d•$61,861 - $96,657

About The Position

The RN, Case Manager assesses and identifies patient and family needs, applies 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 homes as long as possible. The role provides and manages direct care, supports patients and families, and coordinates an individualized Plan of Care that reflects changing needs. The case manager conducts home visits and assessments, educates patients, families, caregivers, and health professionals, reports changes in condition, and collaborates with the IDT and physicians. The role may also provide phone reassurance and coordinate in-person visits, depending on location. During emergencies, the RN may be required to report to a company-designated location earlier than scheduled and remain overnight as needed to ensure continuity of services.

Requirements

Current Registered Nurse (RN) license in the state where the employee will work.
Minimum of 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 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, with or without reasonable accommodation, including lifting patients or equipment, bending, pushing or pulling, and kneeling.
Active Basic Life Support (BLS) certification for healthcare professionals from the American Heart Association or Red Cross.
Satisfactory completion of position competency requirements.
Willingness to report to a company-designated location during emergencies and, if required, work ahead of schedule or stay overnight to maintain continuity of services.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Provide and manage direct patient and family care as part of the Interdisciplinary Team, 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 accurately reflects the patient’s evolving needs.
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 safety, medication and nutritional compliance, durable medical equipment compliance, and the patient’s 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 and present concise, pertinent oral and written reports while respecting and encouraging input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors, using positive approaches.
Supervise care provided by Community Health Workers and Home Health Aides as requested.
When applicable, provide phone reassurance to patients and families, help resolve questions, recognize when an in-person visit is needed, and coordinate visits.
Use appropriate support resources or personnel to resolve complex 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 empathetically, and help put them at ease.
Provide information to physicians and IDT members and initiate the Plan of Care to address immediate patient needs.
Initiate skilled nursing interventions to support prevention, prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation in accordance with Company policy.
Represent the Company at assigned facilities, facilitate referrals to service lines, and 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 strong relationships with case managers, physicians, and other facility contacts.
During emergencies, report to a company-designated location as required, potentially ahead of the scheduled time and overnight.
Represent the Company professionally; comply with applicable regulations, Company policies, and health, safety, security, and confidentiality practices.
Use resources responsibly, participate in community and professional organizations, and contribute to performance improvement and quality activities.
Maintain and improve professional knowledge, skills, and electronic media skills; support Company research and education activities and share expertise with coworkers.
Complete other duties as assigned.