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

- 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.

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.