RN, Care Coordinator- Team - Hope Healthcare-Patient Homes

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, 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 participants 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, with or without reasonable accommodation.
• Active BLS for healthcare professionals from the American Heart Association or Red Cross.
• Some locations may require:
  • 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: provides services, addresses questions, etc.
  • 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.

• Provides and manages direct care to patients and families as part of 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.
• Performs patient assessments and evaluates home safety, medication compliance, nutritional compliance, DME compliance, to determine ability to live safely in the community.
• Reports changes in 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.
• Prepares concise and pertinent oral and written reports to IDT; respects and encourages input from all disciplines.
• Communicates accurately and completely to physicians,…