RN Care Coordinator

Job Profile Summary The RN, Care Coordinator 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. 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 Job Responsibilities Provides and manages direct care to patients and families as part of the 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 accurately reflects the patient’s evolving needs. Educates patients, families, caregivers and other health professionals about disease process, decline, prevention, palliative interventions, caregiving, dying process and safety practices. Participant visit frequency depends 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. Provides concise and pertinent oral and written reports to the 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. 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 the 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. During times of emergencies (i.e. hurricanes, etc.) the RN, Case Manager may be required to report to 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. Competencies Satisfactorily complete competency requirements for this position. 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. Physical Demands 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 & Other Information 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 ongoing 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 #J-18808-Ljbffr Chapters Health