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RN, Care Coordinator
RN, Care CoordinatorChapters Health System • Tavares, FL, United States
RN, Care Coordinator

RN, Care Coordinator

Chapters Health System • Tavares, FL, United States
3 days ago
Job type
  • Full-time
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!

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
  • 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.

    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.

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    Rn Care Coordinator • Tavares, FL, United States

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