RN Case Manager – Facility Team

Chapters Health System

. Assess and identify patient/family needs using the nursing process .

Posted 10/15/2026full-timeNew Port Richey • Florida • United StatesJunior💰 $61,861 - $96,657 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in patient assessment, care coordination, and interdisciplinary collaboration, with a strong focus on palliative and supportive care. Proficient in utilizing EMR systems for documentation and communication while ensuring compliance with healthcare regulations.

Highest-signal resume keywords

Registered Nurse LicensePalliative CareEMR/EHR ExperienceBLS CertificationPatient Assessment

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Patient AssessmentCare CoordinationClinical DocumentationSkilled Nursing InterventionsHome VisitsMedication ComplianceSafety AssessmentsInterdisciplinary CollaborationCultural CompetencePatient Education

Soft Skills

Effective CommunicationRelationship BuildingTeam CollaborationProblem SolvingEmpathy

Tools & Technologies

Electronic Medical Record (EMR) SystemTelephone CommunicationVisual and Auditory Equipment

Certifications & Qualifications

Registered Nurse LicenseBLS CertificationAlzheimer's Disease and Related Dementias Training

Industry Keywords

Hospice CarePalliative CareInterdisciplinary Team (IDT)Patient-Centered CareHome Health CareDrug-Free Workplace PolicyFlorida Care Provider Background Screening

About the role

Key responsibilities & impact

Assess and identify patient/family needs using the nursing process
Coordinate the Plan of Care with the Interdisciplinary Team (IDT)
Provide clinical, palliative, supportive, psychosocial, spiritual, cultural, physical, and biological care to patients and families
Provide telephone reassurance and determine when in-person visits are needed
Coordinate in-person visits and use appropriate support or expert resources for complex situations
Document patient/family contacts and clinical information in the EMR
Complete initial and semi-annual assessments for Company services
Explain services and address patient/family questions and concerns
Initiate Plans of Care and skilled nursing interventions
Obtain physician orders and complete documentation according to Company policy
Represent the Company at assigned facilities and facilitate referrals across service lines
Collaborate frequently with IDT members, physicians, hospitals, facilities, patients, families, and the public
Provide timely clinical communication using SBAR
Discuss potential needs with after-hours staff
Develop relationships with facility case managers and physicians
Coordinate individualized Plans of Care as patient needs evolve
Educate patients, families, caregivers, and health professionals about disease processes, palliative interventions, caregiving, dying processes, and safety practices
Conduct home visits to assess safety, medication compliance, nutritional compliance, DME compliance, and ability to live safely in the community
Report patient condition changes to IDT members and other health professionals
Participate in hospice referral/admission evaluations and daily IDT collaboration meetings
Present concise oral and written reports to the IDT
Supervise care provided by Community Health Workers and Home Health Aides as requested
Report to designated company locations during emergencies and remain overnight when required for continuity of services
Perform other duties as assigned

Requirements

What you’ll need

Current license as RN in the state where the employee will be working
Minimum of one (1) year nursing experience in 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 lifting patients and/or equipment, bending, pushing/pulling, and kneeling, with or without reasonable accommodation
Active BLS for healthcare professionals from the American Heart Association or Red Cross
Consent to drug and/or alcohol testing after a conditional offer of employment
Ongoing compliance with the Drug-Free Workplace Policy
Eligibility verification through the Florida Care Provider Background Screening Clearinghouse