RN, Care Coordinator
2 weeks ago
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, Care Coordinator is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Group (IDG), and providing palliative and supportive care to the patient/family unit.
Qualifications
- Current license as RN in the state where the employee will be working
- Minimum one (1) year of in-patient nursing or hospice experience for external candidates; for internal applicants, minimum of 6-months of LPN experience with hospice/home health within an affiliate
- 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)
- Flexible schedule to meet the needs of Hospice House patients
- Ability to manage the emotional stress of working with and caring for terminally ill patients and their families
- Ability to physically access patient rooms, other areas of the Hospice House/Hospital/ALF, etc., and any home (i.e., navigate stairs and narrow spaces, tolerate heat and lack of air conditioning) within any part of the service area
- 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. Employees hired prior to 12/31/2022 must obtain certificate prior to 10/1/2023
- 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.
- Assists the patient and family to achieve the desired comfort levels.
- 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 Group (IDG).
- Completes clinical admissions for all Company services including, but not limited to:
- Explains services to potential patients/families and addresses questions regarding patient fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner
- Identifies admission objections, concerns or other entry barriers and provides responses
- Educates patient/family on admission requirements and addresses immediate needs
- Completes informed consents and initial assessment according to regulations and Company policy
- Provides information to Physicians and initiates Plan of Care to address patient’s immediate needs
- Initiates skilled nursing interventions to 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 Admissions to ensure timely follow-up. When assignment is complete, informs Admissions and prepares for next assignment.
- Provides all necessary clinical communication timely using SBAR.
- Discusses any potential needs with after-hours staff.
- Obtains consents for services and arranges safe discharge in an efficient manner for referred and eligible patients while meeting productivity expectations.
- Obtains medical record information for the referral.
- Develops strong relationships with case managers, physicians, etc. at facilities.
- Works with Professional Relations Representatives (PRRs) to provide education on all available services.
- Provides care for any GIP patients in a hospital including daily visits, professional management, documentation and efficient discharge.
- Satisfactorily complete competency requirements for this position.
- 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.
- Provides and manages direct care to patients and families as part of Interdisciplinary Group (IDG), 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, palliative interventions, care giving, dying process and safety practices.
- Reports changes in the patient’s condition to appropriate members of the IDG or other health professionals.
- Participates with the IDG to evaluate hospice referrals/admissions for level of care appropriateness.
- Attends patient deaths; prepares body for transport; oversees disposal of medications.
- Provides appropriate bereavement interventions to the family and caregiver in conjunction with psychosocial staff.
- Presents concise and pertinent oral and written reports to IDG; 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 given by other nursing team members (i.e., LPNs, Hospice Aides, and contract nurses).
- Performs other duties as assigned.
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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