RN Field Case Manager

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, 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 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. * 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. 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 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. 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.