<p>It's inspiring to work with a company where people truly BELIEVE in what they're doing!</p> <p>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!</p> <p>Role:</p> <p>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.</p> <p>Qualifications:</p> <ul> <li>Current license as RN in the state where the employee will be working </li><li>Minimum one (1) year of nursing, preferable to have experience with home health, skilled nursing, and/or case management </li><li>Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system </li><li>Mobile Driver - Valid driver's license and automobile insurance per Company policy </li><li>Reliable transportation to meet visit schedule </li><li>Ability to use equipment with visual and auditory mechanisms </li><li>Ability to effectively communicate in English (verbal and written) </li><li>Ability to visit Participant in their homes to assessments </li><li>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 </li><li>Active BLS for healthcare professionals from the American Heart Association or Red Cross. </li></ul> <p>Some locations may require:</p> <ul> <li> <p>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.</p> </li><li> <p>Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations.</p> </li><li> <p>Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT).</p> </li><li> <p>Completes initial and semi-annual assessment for all Company services including, but not limited to:</p> </li><li> <p>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</p> </li><li> <p>Provides information to Physicians and other IDT members and initiates Plan of Care to address patient's immediate needs</p> </li><li> <p>Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort</p> </li><li> <p>Obtains Physician orders</p> </li><li> <p>Completes documentation per Company policy</p> </li><li> <p>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.</p> </li><li> <p>Communicates frequently with other members of the IDT.</p> </li><li> <p>Provides all necessary clinical communication timely using SBAR.</p> </li><li> <p>Discusses any potential needs with after-hours staff.</p> </li><li> <p>Develops strong relationships with case managers, physicians, etc. at facilities.</p> </li></ul> <p>Competencies:</p> <ul> <li>Satisfactorily complete competency requirements for this position. </li></ul> <p>Responsibilities of all employees:</p> <ul> <li>Represent the Company professionally at all times through care delivered and/or services provided to all clients. </li><li>Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse. </li><li>Comply with Company policies, procedures and standard practices. </li><li>Observe the Company's health, safety and security practices. </li><li>Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company. </li><li>Use resources in a fiscally responsible manner. </li><li>Promote the Company through participation in community and professional organizations. </li><li>Participate proactively in improving performance at the organizational, departmental and individual levels. </li><li>Improve own professional knowledge and skill level. </li><li>Advance electronic media skills. </li><li>Support Company research and educational activities. </li><li>Share expertise with co-workers both formally and informally. </li><li>Participate in Quality Assessment and Performance Improvement activities as appropriate for the position. </li></ul> <p>Job Responsibilities:</p> <ul> <li>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. </li><li>Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient's evolving needs. </li><li>Educates patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices. </li><li>Participant visit frequency dependent on risk score/needs to be determined </li><li>Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance- ability to live safely in the community. </li><li>Reports changes in the patient's condition to appropriate members of the IDT or other health professionals. </li><li>Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness. </li><li>Attends daily IDT collaboration meetings </li><li>Presents concise and pertinent oral and written reports to IDT; respects and encourages input from all disciplines. </li><li>Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others. </li><li>Supervises patient care provided by Community Health Workers and Home Health Aides as requested. </li><li>Performs other duties as assigned. </li></ul> <p>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.):</p> <p>While performing the duties of this job, the following abilities are required: see; hear; talk; walk; use hands to finger, handle or feel.</p> <p>Frequently required to: stand; sit; reach with hands/arms; lift; bend; balance.</p> <p>Occasionally required to: pull; push; stoop/crouch; kneel; climb stairs.</p> <p>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.</p>