RN, Case Manager - Capital Caring Health

About the Role

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.

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 keep participants 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 in hospice or hospital (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 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 physical functions (lifting patients/equipment, bending, pushing/pulling, kneeling) with or without reasonable accommodation.
• Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.

Competencies

Satisfactorily complete competency requirements for this position.

Responsibilities

• Provide and manage direct care to patients and families as part of the Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical, and biological components with appropriate nursing interventions and follow‑up.
• Coordinate an individualized Plan of Care that accurately reflects the patient’s evolving needs.
• Educate patients, families, caregivers, and other health professionals about disease processes, prevention, palliative interventions, caregiving, the dying process, and safety practices.
• Conduct home visits to assess home safety, medication compliance, nutritional compliance, and DME compliance, ensuring the participant can live safely in the community.
• Report changes in the patient’s condition to appropriate members of the IDT or other health professionals.
• Participate with the IDT to evaluate hospice referrals/admissions for level‑of‑care appropriateness.
• Attend daily IDT collaboration meetings and present concise oral and written reports, encouraging input from all disciplines.
• Communicate accurately and completely with physicians, staff, patients, families, and supervisors, utilizing positive approaches.
• Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
• Provide reassurance to patients and families over the phone, assist in finding solutions to their questions, and coordinate in‑person visits when needed.
• Utilize appropriate support or expert resources to resolve complex or difficult situations.
• Document patient/family contact information in the EMR and communicate with the IDT.
• Complete initial and semi‑annual assessments for all company services, explain services to patients/families, and address questions with empathy and compassion.
• Obtain physician orders and complete documentation per company policy.
• Act as the company representative at assigned facilities, facilitating referrals to all service lines and working closely with hospitals, physicians, facilities, patients, families, and the public.
• Use SBAR to provide timely clinical communication.
• Develop strong relationships with case managers, physicians, and other stakeholders at facilities.
• During emergencies (e.g., hurricanes), report to a designated location, potentially ahead of schedule and stay overnight as needed to ensure continuity of services.
• Perform other duties as assigned.

Physical Demands

While performing the duties of this job, the following abilities are required: see, hear, talk, walk, and use hands to finger, handle, or feel. Frequently required to stand, sit, reach with hands/arms, lift, bend, and balance. Occasionally required to pull, push, stoop/crouch, kneel, and climb stairs.

Compensation

Pay Range: $69,720.00 – $103,771.25