**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!**Monday-Friday 8am to 5pmBENEFITS BEGIN DAY 1!SIGN ON BONUS AVAILABLE!Job Profile SummaryRole: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 DescriptionQualifications:- Current license as RN in the state where the employee will be working- Minimum of one (1) year nursing experience in 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.- 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.Physical Demands for Post Offer/Pre-Placement (The demands described below are representative of those that must be met by an individual to perform the essential functions of the job, with or without reasonable accommodation.):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 is made, as well as on-going 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 is made as well as ongoing eligibility. For more information, please visit** **.****Choices. Education. Guidance.**As a progressive leader and premier health organization, Chapters Health System is dedicated to delivering innovative care throughout chronic illness progression and beyond.Since 1983 as a community-based, not-for-profit organization, Chapters Health has provided choices, education and guidance through its managed affiliates: Capital Caring Health,