RN Care Coordinator

Job Profile Summary

The RN, Care Coordinator 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 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

• Provide and manage 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.
• Coordinate the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
• Educate patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, caregiving, dying process and safety practices.
• Conduct home visits to assess home safety, medication compliance, nutritional compliance, DME compliance and ability to live safely in the community.
• Report changes in the patient’s condition to appropriate members of the IDT or other health professionals.
• Participate with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.
• Attend daily IDT collaboration meetings.
• Present concise oral and written reports to IDT; respect and encourage input from all disciplines.
• Communicate accurately and completely to physicians, staff members, patients, families, and supervisors; utilize positive approaches when working with others.
• Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
• During emergencies (e.g., hurricanes), report to location designated by the company to ensure continuity of services.
• Perform other duties as assigned.

• Satisfactorily complete competency requirements for this position.
• 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.
• Maintain confidentiality of patients, families, colleagues.
• 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.

While performing the duties, 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 as well as ongoing compliance with the Drug‑Free Workplace Policy. All Chapters Health System employees performing services for Florida affiliates are submitted through the Florida Care Provider Background Screening Clearinghouse to verify eligibility after a conditional offer of employment and ongoing eligibility.