RN, Care Coordinator

Job Profile Summary

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.

• 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 professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices.
  • Participant visit frequency dependent on risk score/needs to be determined.
  • Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance – 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.
• Present concise and pertinent oral and written reports to 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 times of emergencies (i.e. Hurricanes, etc.), the RN, Case Manager may be required to report to work at a location designated by the company, to ensure continuity of services. This may include reporting to work ahead of your scheduled date/time due to planned lock down of unit, and staying overnight(s) based on duration of emergency.
• Performs other duties as assigned.

• 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.
• Consent to drug and/or alcohol testing after a conditional offer of employment is made, and ongoing compliance with the Drug-Free Workplace Policy.
• Must be submitted through the Florida Care Provider Background Screening Clearinghouse to verify eligibility after a conditional offer of employment is made as well as ongoing eligibility.

• 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: $60,058.27 - $90,087.92

Background screening: