Case Manager Jobs in San Antonio, FL

About The Position

Requirements

• Current Registered Nurse 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: certificate of completion of 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 to conduct assessments.
• Ability to perform essential job functions and physical requirements, with or without reasonable accommodation, including lifting patients and/or equipment, bending, and pushing or pulling.
• Active BLS for healthcare professionals certification from the American Heart Association or Red Cross.
• Satisfactorily complete the 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 services performed for Florida affiliates, pass eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and maintain ongoing eligibility.

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 IDT, 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.
• Complete initial and semiannual assessments for Company services.
• Explain services to patients and families, address questions and concerns, and present services empathetically and compassionately.
• Provide information to physicians and IDT members and initiate Plans of Care to address immediate patient needs.
• Initiate skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
• Obtain physician orders and complete documentation according to Company policy.
• Educate patients, families, caregivers, and other health professionals about disease process and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
• Conduct home visits to assess home safety, medication compliance, nutritional compliance, durable medical equipment compliance, and ability to live safely in the community; determine visit frequency based on risk score and needs.
• 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 and attend daily IDT collaboration meetings.
• Present concise and pertinent oral and written reports to the IDT and encourage input from all disciplines.
• Communicate accurately and completely with physicians, staff, patients, families, and supervisors; use SBAR for timely clinical communication.
• Provide phone reassurance to patients and families at some locations, help resolve questions, recognize when an in-person visit is needed, coordinate visits, use appropriate support resources, document contacts in the EMR, and communicate with the IDT.
• Discuss potential needs with after-hours staff.
• Act as the Company representative at assigned facilities and facilitate referrals to service lines while working with referring hospitals, physicians, facilities, patients, families, and the general public.
• Develop strong relationships with facility case managers, physicians, and others.
• 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 the scheduled time and staying overnight to ensure continuity of services.
• Represent the Company professionally; comply with applicable regulations and Company policies; observe health, safety, and security practices; and maintain confidentiality.
• Use resources responsibly, participate in community and professional organizations, support performance improvement and Quality Assessment and Performance Improvement activities, improve professional knowledge and electronic media skills, support research and educational activities, and share expertise with coworkers.
• Perform other duties as assigned.