Registered Nurse Care Coordinator

It's inspiring to work with a company where people truly BELIEVE in what they're doing! When you become part of the Chapters Health Team, you'll realize it's more than a job. It's a mission. We're committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success! 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. Job Description 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. Some locations may require: * Provides reassurance on the phone to patients and families. Assists in finding solutions to their questions and/or recognizes the need for an in person visit. Coordinates in person visit when needed/or requested. * Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations. * Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT). * Completes initial and semi-annual assessment for all Company services including, but not limited to: * Explains services to patients/families and addresses questions regarding patient needs, fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner * Provides information to Physicians and other IDT members and initiates Plan of Care to address patient's immediate needs * Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort * Obtains Physician orders * Completes documentation per Company policy * Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public. * Communicates frequently with other members of the IDT. * Provides all necessary clinical communication timely using SBAR. * Discusses any potential needs with after-hours staff. * Develops strong relationships with case managers, physicians, etc. at facilities. Competencies: * Satisfactorily complete competency requirements for this position. Responsibilities of all employees: * Represent the Company professionally at all times through care delivered and/or services provided to all clients. * Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse. * Comply with Company policies, procedures and standard practices. * Observe the Company's health, safety and security practices. * Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company. * Use resources in a fiscally responsible manner. * Promote the Company through participation in community and professional organizations. * Participate proactively in improving performance at the organizational, departmental and individual levels. * Improve own professional knowledge and skill level. * Advance electronic media skills. * Support Company research and educational activities. * Share expertise with co-workers both formally and informally. * Participate in Quality Assessment and Performance Improvement activities as appropriate for the position. Job 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 * 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. Physical Demands for Post Offer/Pre-Placement (The demands described below are representative of those that must be met by an individual to perform the essential functions of the job, with or without reasonable accommodation.): While performing the duties of this job, the following abilities are required: 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: $61,860.66 - $96,657.28 This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy. All Chapters Health System employees performing services for Florida affiliates are 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. For more information, please visit