RN, Case Manager - Capital Caring Health - Arlington, VA

Job Profile Summary

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 in order to keep the participant in their home environment as long as possible.

• 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 must have 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 for 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

• 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 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.

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.

• Provides and manages direct…