RN, Care Coordinator M

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) 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 additional certification

• 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/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, explaining services to patients/families, addressing questions regarding patient needs, fears, and physical limitations, and presenting 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 and works closely with referring hospitals, physicians, facilities, patients, families, and the general public
• Communicates frequently with other members of the IDT and 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 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
• Conducts home visits to assess home safety, medication compliance, nutritional compliance, DME compliance and the 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 and attends daily IDT collaboration meetings
• Prepares concise and pertinent oral and written reports to the IDT and encourages input from all disciplines
• Communicates accurately and completely to physicians, staff members, patients, families, and supervisors, utilizing…