RN, Care Coordinator M-TH

chaptershealth; Ocala (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

The Chapters Health RN Case Manager assesses patient and family needs, coordinates the Plan of Care with the Interdisciplinary Team, and provides clinical, palliative and supportive care to patients in their homes.

Responsibilities include coordinating visits, EMR documentation, and clear communication with physicians, IDT members, patients and families to ensure compassionate, high-quality care.

Qualifications

• Active RN license in Florida.
• Minimum 1 year nursing experience; hospice or hospital preferred.
• PACE program training via Florida Dept. of Elder Affairs may be required.
• Experience with an EMR/EHR system.
• Valid driver’s license and auto insurance; reliable transportation.

Responsibilities

• Assess patient and family needs and coordinate the Plan of Care with the Interdisciplinary Team (IDT).
• Provide clinical, palliative and supportive care to keep the patient at home.
• Document in EMR and communicate with IDT, physicians and families.
• Initiate and supervise nursing interventions to enhance comfort and safety.
• Perform initial assessments and explain services to patients and families empathetically.

Skills

RN license

EMR/EHR experience

BLS

Valid driver's license

English communication

Physical stamina

Education

Registered Nurse (RN) license in Florida

Tools

EMR/EHR system

Job description

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!

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.

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 (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.

Some locations may require:

Provides reassurance on the phone to patients and families. Assists in finding solutions to their questions and/or recognizes the need for an in person visit. Coordinates in person visit when needed/or requested.

Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations.

Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT).

Completes initial and semi-annual assessment for all Company services including, but not limited to: Explains services to patients/families and addresses questions regarding patient needs, fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner

Provides information to Physicians and other IDT members and initiates Plan of Care to address patient's immediate needs

Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort

Obtains Physician orders

Completes documentation per Company policy

Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public.

Communicates frequently with other members of the IDT.

Provides all necessary clinical communication timely using SBAR.

Discusses any potential needs with after-hours staff.

Develops strong relationships with case managers, physicians, etc. at facilities.

Competencies:

• Satisfactorily complete competency requirements for this position.

Responsibilities of all employees:

• 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, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.
• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• 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.

Job 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.
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