PACE RN Case Manager - Citrus County

Chapters Health System; Lecanto (FL); On-site; USD 61,860 - 96,657; Full time

Job summary

Chapters Health System is seeking an RN, Case Manager to assess patient and family needs, coordinate Plan of Care with the IDT, and provide clinical and supportive care in the home setting to keep patients in their home environment as long as possible.

The role requires active Florida RN license, at least 1 year nursing experience, and a valid driver's license. Home visits, EMR use, and collaboration with the interdisciplinary team are essential to ensure quality hospice care.

Qualifications

• 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
• Alzheimer's Disease and Related Dementias Training certification (Florida) for PACE
• Experience using an EMR/EHR system
• Valid driver’s license and automobile insurance per policy
• Reliable transportation to meet visit schedule
• Ability to visit participants in their homes for assessments
• Active BLS for healthcare professionals

Responsibilities

• 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, caretaking, dying process and safety practices
• Participant visit frequency depends 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 and 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 emergencies (e.g., hurricanes), may be required to report to a designated location to ensure continuity of services, including reporting early and staying overnight as needed
• Performs other duties as assigned

Skills

Effective communication in English

Mobility to visit patient homes

Time management

Education

RN license in Florida

Tools

EMR/EHR system

BLS certification

Job description

RN, Case Manager

Job Profile Summary: The RN, Case Manager assesses and identifies patient/family needs, utilizes the nursing process, coordinates the Plan of Care with the Interdisciplinary Team (IDT), and provides clinical, palliative and supportive care to the patient/family unit, keeping the participant in their home environment as long as possible.

Job Description Qualifications

• 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
• Effective communication in English (verbal and written)
• Ability to visit participants in their homes for assessments
• Ability to perform essential physical functions (lifting, bending, pushing/pulling, kneeling) with or without reasonable accommodation
• Active BLS for healthcare professionals from the American Heart Association or Red Cross

Competencies

• Satisfactorily complete competency requirements for this position

Responsibilities

• 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, caretaking, dying process and safety practices
• Participant visit frequency depends 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 and 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 emergencies (e.g., hurricanes), may be required to report to a designated location to ensure continuity of services, including reporting early and staying overnight as needed
• Performs other duties as assigned

Physical Demands

While performing the duties of this job, 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.

Compensation

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. For more information, please visit https://info.flclearinghouse.com/.