Home-Based RN Case Manager: Patient-Centered Care

Chapters Health System; Aldie (VA); On-site; USD 70,000 - 104,000; Full time

Job summary

Chapters Health System is seeking an experienced RN, Case Manager to assess patient and family needs, coordinate the Plan of Care with the Interdisciplinary Team, and provide clinical, palliative and supportive care to help patients remain at home.

The role prioritizes home visits, coordination with IDT, clear communication, patient education, and timely documentation, ensuring compassionate, quality care across our service area.

Qualifications

• Certification: Active BLS for healthcare professionals from the American Heart Association or Red Cross.
• Experience with EMR/EHR systems.
• Mobile driver with valid license and automobile insurance; reliable transportation for visit schedule.
• Ability to communicate in English (verbal and written).
• Ability to visit participants in their homes and perform essential functions with or without accommodation.

Responsibilities

• 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, Presents 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.

Skills

RN Case Manager

Home health care

Interdisciplinary Team coordination

Education

Alzheimer’s Disease & Related Dementias Training (PACE Florida)

Tools

EMR/EHR system

Job description

Chapters Health System is seeking an experienced RN, Case Manager to assess patient and family needs, coordinate the Plan of Care with the Interdisciplinary Team, and provide clinical, palliative and supportive care to help patients remain at home.

The role prioritizes home visits, coordination with IDT, clear communication, patient education, and timely documentation, ensuring compassionate, quality care across our service area.