RN, Case Manager - (HPH Hospice) - Alachua Office

Chapters Health•Alachua, FL

6d•Hybrid

About The Position

The RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative and supportive care to the patient/family unit in order to keep the participant in their home environment as long as possible. This role involves providing reassurance on the phone, assisting with questions, recognizing the need for in-person visits, coordinating visits, and utilizing support resources for complex situations. The Case Manager documents patient/family contact in the EMR, communicates with the IDT, and completes initial and semi-annual assessments. They explain services, address patient/family needs, present services empathetically, provide information to physicians and IDT members, initiate Plans of Care, and perform skilled nursing interventions. The role also involves obtaining physician orders, completing documentation, acting as a company representative at facilities, facilitating referrals, and communicating with physicians, facilities, patients, families, and the public. Frequent communication with the IDT, timely clinical communication using SBAR, discussing potential needs with after-hours staff, and developing strong relationships with case managers and physicians are key aspects. The RN, Case Manager also supervises patient care provided by Community Health Workers and Home Health Aides as requested. During emergencies, they may be required to report to a company-designated location to ensure service continuity, potentially including reporting before their scheduled date/time and staying overnight.

Requirements

Current license as RN in the state where the employee will be working
Minimum of one (1) year nursing experience
Employees working at PACE, certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs
Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
Mobile Driver - Valid driver’s license and automobile insurance per Company policy
Reliable transportation to meet visit schedule
Ability to use equipment with visual and auditory mechanisms
Ability to effectively communicate in English (verbal and written)
Ability to visit Participant in their homes to assessments
Ability to perform the essential functions and physical requirements (including, but not limited to: lifting patients and/or equipment, bending, pushing/pulling, kneeling) of the job with or without reasonable accommodation
Active BLS for healthcare professionals from the American Heart Association or Red Cross.

Nice To Haves

hospice or hospital experience preferred

Responsibilities

Provides and manages direct care to patients and families as part of Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
Educates patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices.
Conducts home visits to assess home safety, medication compliance, nutritional compliance, DME compliance, and ability to live safely in the community.
Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals.
Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.
Attends daily IDT collaboration meetings.
Presents concise and pertinent oral and written reports to IDT; respects and encourages input from all disciplines.
Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others.
Supervises patient care provided by Community Health Workers and Home Health Aides as requested.
During times of emergencies (i.e. Hurricanes, etc.), the RN, Case Manager may be required to report to work at a location designated by the company, to ensure continuity of services. This may include reporting to work ahead of your scheduled date/time due to planned lock down of unit, and staying overnight(s) based on duration of emergency.
Performs other duties as assigned.