RN, Case Manager - Float Team; HPH Hospice

Overview

Chapters Health is a community‑based, not‑for‑profit organization dedicated to providing patient‑centered care. The RN, Case Manager will assess and identify patient and family needs, use the nursing process, coordinate the Plan of Care with the Interdisciplinary Team (IDT), and deliver clinical, palliative and supportive care to keep participants in their home environments as long as possible.

• Assess and identify patient/family needs using the nursing process.
• Coordinate the Plan of Care with the IDT, ensuring it reflects evolving patient needs.
• Provide clinical, palliative and supportive care while keeping patients in their homes.
• Visit participants in their homes to assess safety, medication compliance, nutritional compliance, and DME compliance.
• Document patient/family contact 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 regarding patient needs, fears, and physical limitations.
• Provide information to physicians and other IDT members and initiate the Plan of Care for immediate needs.
• Initiate skilled nursing interventions to prevent complications, alleviate symptoms and maximize comfort.
• Obtain physician orders and complete documentation per company policy.
• Act as the company representative at assigned facilities and facilitate referrals to all service lines.
• Communicate frequently with other IDT members using SBAR.
• Develop strong relationships with case managers and physicians at facilities.
• Participate in daily IDT collaboration meetings and present concise oral and written reports.
• Supervise patient care provided by community health workers and home health aides as requested.
• Report changes in patient condition to appropriate IDT or health professionals.
• Assist in finding solutions to patient/family questions and coordinate in‑person visits when needed.
• Participate with the IDT to evaluate hospice referrals for level of care appropriateness.
• During emergencies (e.g., hurricanes) report to an alternate work location to ensure continuity of services.
• Perform other duties as assigned.

• Current RN license in the state of employment.
• Minimum of one year of nursing experience; hospice or hospital experience preferred.
• Completion of Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs for PACE employees.
• Previous experience working with an EMR/EHR system.
• Valid driver’s license and automobile insurance; reliable transportation for visit schedule.
• Ability to use equipment with visual and auditory mechanisms.
• Effective communication in English (verbal and written).
• Physical ability to visit participants in their homes for assessments.
• Capability to perform essential functions including lifting patients or equipment, bending, pushing/pulling, kneeling.
• Active BLS certification from the American Heart Association or Red Cross (if required).

• Comply with state, federal and local regulations.
• Adhere to company policies, procedures and standard practices.
• Maintain confidentiality of patients, families, colleagues and other sensitive situations.
• Use resources in a fiscally responsible manner.
• Promote the company through community and professional engagement.
• Continuously improve own professional knowledge and skills.
• Support company research, educational activities and quality improvement initiatives.

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

Base pay range: $60,058.27 – $90,087.92 per year.

Position requires consent to drug and/or alcohol testing after a conditional offer of employment and ongoing compliance with the Drug‑Free Workplace Policy. All employees performing services for Florida affiliates must be submitted to the Florida Care Provider Background Screening Clearinghouse for eligibility verification after a conditional offer is made and ongoing eligibility.