RN, Care Coordinator Mulberry​/Bartow

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 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 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

• 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 visits when needed or requested
• Utilizes appropriate support or expert resources to resolve complex or difficult situations
• Documents patient/family contact information in the EMR and communicates with the IDT
• Completes initial and semi‑annual assessment for all Company services, explains services to patients/families, addresses questions regarding patient needs, fears, physical limitations, while putting the patient/family at ease, and presents services in an empathetic and compassionate manner
• Provides information to Physicians and other IDT members, initiates Plan of Care to address patient’s immediate needs, and 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; provides all necessary clinical communication timely using SBAR; discusses 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 the IDT, incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow‑up
• Coordinates the Plan of Care, ensuring that an individualized Plan of Care 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
• Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness; attends daily IDT collaboration meetings
• Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals
• Supervises patient care provided by Community Health Workers and Home Health Aides as requested
• Satisfies physical demands of the role and reports at alternate locations during emergencies (e.g., hurricanes) as required
• Performs other duties as assigned

• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse
• Adhere to Company policies, procedures and standard practices
• Observe the Company’s health, safety and security practices
• Maintain the confidentiality of…