RN, Case Manager

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 patient, family, 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 IDT.
• Completes initial and semi-annual assessments for all Company services, including explaining services to patients/families and addressing their questions and concerns.
• 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 and provides all necessary clinical communication timely using SBAR.
• Discusses any potential needs with after-hours staff and 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.
• For 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.
• 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.
• 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

The following abilities are required for the role, 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 employees 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.