RN, Case Manager - Arlington Visits

Join to apply for the RN, Case Manager - Arlington Visits role at Capital Caring Health
.

The RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative and supportive care to the patient/family unit to keep participants in their home environment as long as possible.

• Current RN license in the state where the employee will be working
• Minimum of one (1) year nursing experience; hospice or hospital experience preferred
• Certification of completion of Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs (for PACE employees)
• Previous experience working with an EMR/EHR system
• Valid driver’s license and automobile insurance; reliable transportation to meet visit schedule
• Must be able to use equipment with visual and auditory mechanisms
• Effective verbal and written communication skills in English
• Capability to visit participants in their homes for assessments
• Physical ability to perform essential functions and requirements (lifting patients, bending, pushing/pulling, kneeling)
• Active BLS certification for healthcare professionals from the American Heart Association or Red Cross

• Provide and manage direct care to patients and families as part of the IDT, integrating psychosocial, spiritual, cultural, physical and biological components.
• Coordinate the Plan of Care, ensuring individualized plans reflect evolving patient needs.
• Educate patients, families, caregivers, and other health professionals about disease progression, prevention, palliative interventions, caregiving, end‑of‑life practices, and safety.
• Conduct home visits to assess safety, medication and nutrition compliance, DME, and overall community living capability.
• Report changes in patient condition to appropriate IDT or health professional members.
• Participate with the IDT in evaluating hospice referrals and admissions for appropriate level of care.
• Attend daily IDT collaboration meetings and present concise oral and written reports.
• Communicate accurately and fully with physicians, staff, patients, families, and supervisors.
• Supervise patient care provided by Community Health Workers and Home Health Aides as needed.
• Respond to emergency situations (e.g., hurricanes) by reporting to designated work locations, possibly at short notice or overnight.
• Provide reassurance on the phone to patients and families, assist in finding solutions to their questions, and coordinate in‑person visits when needed or requested.
• Utilize appropriate support/expert resources or personnel to resolve complex or difficult situations.
• Document patient/family contact information in the EMR and communicate with the IDT.
• Complete initial and semi‑annual assessments for all company services, including explaining services, addressing questions, initiating plans of care, obtaining physician orders, and completing documentation per company policy.
• Act as the company representative at assigned facilities while facilitating referrals to all service lines; work closely with referring hospitals, physicians, facilities, patients, families, and the general public.
• Communicate frequently with other IDT members and provide all necessary clinical communication timely using SBAR.
• Discuss any potential needs with after‑hours staff and develop strong relationships with case managers, physicians, etc. at facilities.
• Perform 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.

$66,064.10 – $99,096.71

This position requires consent to drug and/or alcohol testing after a conditional offer of employment, as well as ongoing compliance with the Drug‑Free Workplace Policy.

Entry level

Full‑time

Health Care Provider;
Hospitals and Health Care, Non‑profit Organizations, and Mental Health Care