RN-Case Manager-PACE Program-Fort Myers

Chapters Health System•Fort Myers, FL

4d•$61,861 - $96,657

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 includes direct patient and family care, home assessments, education, care coordination, and timely communication with the IDT and other health professionals. The position is based on a Monday–Friday daytime schedule and includes home visits. Visit frequency depends on participant risk score and needs. During emergencies, such as hurricanes, the RN may be required to report to a company-designated location ahead of schedule and may need to stay overnight to ensure continuity of services. The position offers benefits beginning on day one and mileage reimbursement. Compensation is $61,860.66–$96,657.28. A conditional offer requires consent to drug and/or alcohol testing. Florida affiliate employees are subject to background screening and ongoing eligibility verification through the Florida Care Provider Background Screening Clearinghouse.

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.
For employees working at PACE: certification of completion of 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 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 certification from the American Heart Association or Red Cross.
Satisfactory completion of competency requirements for the position.
Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
For employees performing services 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 participant and family needs using the nursing process.
Provide and manage direct patient and family care as part of the IDT, incorporating psychosocial, spiritual, cultural, physical, and biological considerations and appropriate nursing interventions and follow-up.
Coordinate an individualized Plan of Care with the IDT and ensure it reflects the participant’s changing needs.
Educate participants, 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, medication and nutritional compliance, durable medical equipment compliance, and the participant’s ability to live safely in the community.
Report changes in a participant’s condition to appropriate IDT members or other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for appropriate level of care, 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, participants, families, and supervisors, using timely clinical communication such as SBAR.
Supervise care provided by Community Health Workers and Home Health Aides when requested.
Provide reassurance and guidance by phone to participants and families; identify when an in-person visit is needed and coordinate it when requested or appropriate.
Use appropriate support resources or personnel to resolve complex situations; document participant 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, and present services empathetically and compassionately.
Provide information to physicians and IDT members, initiate Plans of Care to address immediate needs, initiate 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 build relationships with case managers, physicians, and other facility contacts.
Discuss potential needs with after-hours staff.
Represent the Company professionally; comply with applicable regulations and Company policies; maintain confidentiality; use resources responsibly; participate in organizational, professional, quality improvement, research, and educational activities; and develop professional and electronic media skills.
During emergencies, report to a company-designated location as required, potentially ahead of the scheduled work time and with overnight stays.
Perform other duties as assigned.