RN, Case Manager-Hope Hospice-Patient Homes

Chapters Health•Cape Coral, FL

11d

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 patients remain in their home environment as long as possible. The role manages direct patient and family care as part of the IDT and supports individualized care as patient needs evolve. Visit frequency is determined by risk score and needs. Home visits assess safety, medication and nutritional compliance, durable medical equipment compliance, and the patient’s ability to live safely in the community. The RN provides education to patients, families, caregivers, and health professionals; reports changes in condition; participates in referral and admission evaluations; and communicates with physicians, IDT members, patients, families, and supervisors. The position may supervise care delivered by Community Health Workers and Home Health Aides. During emergencies, such as hurricanes, the employee may need to report to a company-designated location ahead of schedule and may need to stay overnight to maintain continuity of services. The position offers a schedule of five 8-hour shifts and every other weekend, mileage reimbursement, and benefits beginning on day one. Compensation is $61,860.66–$96,657.28. Employment is contingent on required post-offer drug and/or alcohol testing and background screening, with ongoing compliance requirements.

Requirements

Current Registered Nurse license in the state where the employee will work.
Previous experience working with an electronic medical or health record (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 perform 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 certification for healthcare professionals from the American Heart Association or Red Cross.
Ability to complete the competency requirements for the position.
Employees working at PACE must complete Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.

Nice To Haves

At least one year of nursing experience in hospice or hospital settings is preferred.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Coordinate the Plan of Care with the Interdisciplinary Team and ensure it reflects the patient’s evolving needs.
Provide and manage direct care incorporating psychosocial, spiritual, cultural, physical, and biological considerations, with appropriate nursing interventions and follow-up.
Provide clinical, palliative, and supportive care to patients and families to help patients remain in their home environment as long as possible.
Provide reassurance by phone, help resolve questions, recognize when an in-person visit is needed, and coordinate visits when appropriate.
Complete initial and semi-annual assessments for Company services.
Explain services and address patient and family questions and concerns empathetically and compassionately.
Initiate skilled nursing interventions to prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation in accordance with Company policy.
Educate patients, families, caregivers, and health professionals about disease processes and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety, medication compliance, nutritional compliance, equipment compliance, and ability to live safely in the community.
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.
Communicate clinical information timely and accurately, including using SBAR, and discuss potential needs with after-hours staff.
Act as the Company representative at assigned facilities and facilitate referrals to Company service lines.
Work with referring hospitals, physicians, facilities, patients, families, and the general public; develop relationships with facility case managers and physicians.
Communicate with the IDT and encourage input from all disciplines.
Supervise patient 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 schedule and overnight.
Represent the Company professionally; comply with applicable regulations, policies, procedures, and safety, security, and confidentiality practices.
Use resources responsibly, participate in community and professional organizations, contribute to performance improvement and quality activities, develop professional and electronic media skills, support research and educational activities, and share expertise with coworkers.
Perform other duties as assigned.