RN Case Manager

It's inspiring to work with a company where people truly BELIEVE in what they're doing!

When you become part of the Chapters Health Team, you'll realize it's more than a job. It's a mission. We're committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success!

Role:

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.

Job Description

Qualifications:

* 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 to 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 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.

Competencies:

* Satisfactorily complete competency requirements for this position.

Responsibilities of all employees:

* 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.

Job Responsibilities:

* Provides and manages direct care to patients and families as part of 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 of Care is developed that accurately reflects the patient's evolving needs.

* Educates patient, family, caregivers and other health…