RN-Case Manager-PACE Program-Fort Myers

Chapters Health•Fort Myers, FL

About The Position

The RN, Case Manager is responsible for assessing and identifying participant and family needs, using the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative, and supportive care to help participants remain in their home environment as long as possible. The role includes home visits to assess safety and the participant’s ability to live safely in the community, with visit frequency based on risk score and needs. The position is scheduled Monday through Friday during the day and includes mileage reimbursement. The RN provides and manages direct care as part of the IDT, incorporating psychosocial, spiritual, cultural, physical, and biological needs into nursing interventions and follow-up. The RN educates participants, families, caregivers, and health professionals; monitors and reports changes in condition; coordinates individualized care plans; and communicates clinical information to the IDT and physicians. The role also involves collaboration meetings, supervision of Community Health Workers and Home Health Aides when requested, and serving as a company representative at assigned facilities. During emergencies, the RN may be required to report to a designated location outside the usual schedule and stay overnight as necessary. The position requires a current state RN license, BLS certification, reliable transportation, a valid driver’s license and automobile insurance, and the ability to perform the essential physical functions of the job with or without reasonable accommodation. Employees working at PACE must complete Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs. The stated compensation range is $61,860.66–$96,657.28. Benefits are available beginning on day one. Employment is contingent on required drug and/or alcohol testing after a conditional offer and compliance with the Drug-Free Workplace Policy; Florida affiliate employees are also subject to background-screening eligibility verification.

Requirements

Current RN license in the state where the employee will work.
For employees working at PACE, completion certification for 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, including lifting patients and/or equipment, bending, pushing or pulling, and kneeling, with or without reasonable accommodation.
Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.
Ability to satisfactorily complete the position’s competency requirements.
Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
For Florida affiliate employees, eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and ongoing eligibility.

Nice To Haves

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

Responsibilities

Assess and identify participant and family needs using the nursing process.
Coordinate an individualized Plan of Care with the Interdisciplinary Team (IDT), ensuring it reflects the participant’s evolving needs.
Provide and manage direct patient and family care, including appropriate nursing interventions and follow-up.
Provide reassurance and support by phone, identify when an in-person visit is needed, coordinate visits, and use appropriate support resources to resolve complex situations.
Complete initial and semi-annual assessments for Company services; explain services and address participant and family questions and concerns.
Initiate skilled nursing interventions to support prevention, prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation according to Company policy.
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.
Educate participants, families, caregivers, and health professionals about disease processes, decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Report changes in participant 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 encouraging input from all disciplines.
Communicate clinical information accurately and promptly to physicians, staff, participants, families, and supervisors, including through SBAR; discuss potential needs with after-hours staff.
Serve as the Company representative at assigned facilities and facilitate referrals to Company service lines; develop relationships with case managers, physicians, and other facility contacts.
Supervise care provided by Community Health Workers and Home Health Aides when requested.
During emergencies, report to a company-designated work location as needed, potentially ahead of the scheduled time and with overnight stays, to ensure continuity of services.
Represent the Company professionally; comply with applicable regulations and Company policies; maintain confidentiality; use resources responsibly; and observe health, safety, and security practices.
Participate in community and professional organizations, performance improvement and quality activities, and Company research and educational activities as appropriate; improve professional knowledge and electronic media skills and share expertise with coworkers.
Perform other duties as assigned.