Registered Nurse; RN) Case Manager - Prince George's County - Capital Caring Health

Job 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 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. Some locations may require:

• Provides and manages direct care to patients and families as part of the Interdisciplinary Team (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 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.
• Participant visit frequency dependent on risk score/needs to be determined.
• Conducts home visits to assess home safety, medication compliance, nutritional compliance, DME compliance—to determine ability to live safely in the community.
• Reports changes in the 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; presents concise and pertinent oral and written reports to the IDT; respects and encourages input from all disciplines.
• Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others.
• Supervises patient care provided by Community Health Workers and Home Health Aides as requested.
• During emergencies (e.g., hurricanes), the RN, Case Manager may be required to report to a designated location to ensure continuity of services, which may include reporting ahead of the scheduled date/time and staying overnight(s) based on duration of emergency.
• Performs other duties as assigned.

• 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 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…