RN Care Coordinator M

Role 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
• Valid driver’s license and automobile insurance (Mobile Driver) 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 (e.g., 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, and coordinates in‑person visits 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 assessments for all Company services
• Explains services to patients/families, addresses questions regarding patient needs, fears, physical limitations, and 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 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 any potential needs with after‑hours staff, and develops strong relationships with case managers, physicians, etc. at facilities
• 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 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
• 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 and presents concise and pertinent oral and written reports to IDT
• Communicates accurately and completely to physicians, staff members, patients, families, and supervisors, utilizing 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), may be required to report to work at a designated location, report ahead of scheduled time, and stay overnight based on duration of emergency
• Performs other duties as assigned

While performing the duties of this job, the following abilities are required: see; hear; talk; walk; use hands to finger, handle or feel. Frequently required to: stand; sit; reach with hands/arms; lift; bend; balance. Occasionally required to: pull; push; stoop/crouch; kneel; climb stairs.

Pay Range: $61,860.66 – $96,657.28

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, and ongoing compliance with the Drug‑Free Workplace Policy.