RN, Care Coordinator-4 10hrs weekdays- Sign on bonus and Charter School Eligible

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!

About the 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 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 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 an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
• Educates patients, families, caregivers, and other health professionals about disease process and decline, prevention, palliative interventions, caregiving, dying process, and safety practices.
• Conducts home visits to assess home safety, medication compliance, nutritional compliance, DME compliance, and ability to live safely in the community. Visit frequency dependent on risk score/needs.
• 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 and presents concise, pertinent oral and written reports; 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 questions, and coordinates in-person visits 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 IDdisciplinary Team (IDT).
• Completes initial and semi-annual assessments for all Company services, including explaining services to patients/families and addressing questions regarding patient needs, fears, and physical limitations.
• 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 and 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, and discusses potential needs with after-hours staff.
• Develops strong relationships with case managers, physicians, etc., at facilities.
• During emergencies (e.g., hurricanes), may be required to report to a designated work location to ensure continuity of services, including reporting ahead of schedule or staying overnight.
• Performs other duties as assigned.

Requirements

• 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.
• Certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs (for employees working at PACE).
• Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system.
• 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 participants in their homes for assessments.
• Ability to perform essential functions and physical requirements of the job (including lifting patients and/or equipment, bending, pushing/pulling, kneeling) with or without reasonable accommodation.
• Active BLS for healthcare professionals from the American Heart Association or Red Cross.

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.

Physical Demands

For post-offer/pre-placement, the following abilities are required while performing the duties of this job, with or without reasonable accommodation:

• 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.

Pay

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.