RN, Case Manager-PACE Program-Cape Coral

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 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.