RN, Care Coordinator

Job Profile Summary Role: 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. 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. Participant visit frequency dependent on risk score/needs to be determined. Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance – 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. Present 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. Qualifications Current license as RN in the state where the employee will be working. Minimum of one (1) year nursing experience; hospice or hospital experience preferred. 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. Consent to drug and/or alcohol testing after a conditional offer of employment is made, and ongoing compliance with the Drug-Free Workplace Policy. Must be submitted through the Florida Care Provider Background Screening Clearinghouse to verify eligibility after a conditional offer of employment is made as well as ongoing eligibility. Physical Demands See; hear; talk; walk; use hands to finger, handle or feel. Frequently required to stand; sit; reach with hands/arms; lift; bend; balance. Occasionally required to pull; push; stoop/crouch; kneel; climb stairs. Compensation Pay Range: $60,058.27 - $90,087.92 Background screening: #J-18808-Ljbffr Chapters Health System