Field RN Case Manager​/Sun-Wed Cornerstone Hospice

Overview

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!

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 Group (IDG), and providing palliative and supportive care to the patient/family unit.

• 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
• 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 the essential functions and physical requirements (lifting patients or equipment, bending, pushing or pulling, kneeling) with or without reasonable accommodation
• Active BLS for healthcare professionals from the American Heart Association or Red Cross

• Provide reassurance on the phone to patients and families, assist in finding solutions to their questions and/or recognize the need for an in‑person visit, and coordinate in‑person visits when needed or requested
• Utilize appropriate support or expert resources to resolve complex or difficult situations
• Document patient/family contact information in the EMR and communicate with the Interdisciplinary Team (IDT)
• Complete initial and semi‑annual assessments for all Company services and provide information to physicians and other IDT members to initiate Plan of Care addressing patient’s immediate needs
• Initiate skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort, and obtain physician orders
• Act as the Company representative at assigned facilities, facilitate referrals to all service lines, and work closely with referring hospitals, physicians, facilities, patients, families, and the general public
• Communicate frequently with other members of the IDT and provide all necessary clinical communication in a timely manner using SBAR
• Discuss potential needs with after‑hours staff, develop strong relationships with case managers and physicians at facilities
• Provide and manage direct care to patients and families as part of the IDT, incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing interventions and follow‑up
• Coordinate the Plan of Care, ensuring an individualized plan 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
• 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, and present concise and pertinent oral and written reports to IDT
• Supervise patient care provided by Community Health Workers and Home Health Aides as requested
• During emergencies (e.g., hurricanes), report to a designated location to ensure continuity of services, possibly before scheduled work time and staying overnight as required
• 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…