At Guaranteed Health we are on a mission to change the death and dying experience and are incredibly passionate about improving end-of-life care. We partner with health plans, providers, and other risk-bearing entities to improve outcomes for their highest acuity patients by deploying a value-based and tech-forward care navigation service. We are looking for people to join us on our mission, who are similarly obsessed with patient experience and delivering excellence in care

Position Title: RN Care Manager

Location: Brevard County, Florida

Job Type: Full-Time

Position Summary:

• This full-time position is responsible for managing patients with advanced illness as they transition to hospice. The role will focus on promoting effective education, self-management support, caregiver support, timely care coordination and patient advocacy to achieve optimal transitions to hospice.

• Additionally, this team member will work closely with existing healthcare providers on care plan development and management, including capturing details for end-of-life (EoL) care and patient preferences.

Ongoing Responsibilities:

• Collaborates with providers and practice staff in identifying appropriate patients for hospice navigation, utilizing an established, data-driven identification model to determine which patients are appropriate for hospice services.

• Formulates and implements a EoL care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.

• Establishes an EoL care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific details of EoL care processes, patient preference regarding hospice, ongoing resources/support for patient/caregiver/family members and frequent updates regarding patient status.

• Initiates care conference to discuss the care management plan, patient progress, caregiver/family member support and hospice preferences. Commits to update existing providers (PCP) when changes occur.

• Completes visits with patients that focus on advanced-care planning, managing decline and identifying supports/resources for caregivers.

• Focuses on a specialized patient care approach which includes managing symptoms, relieving pain, and enhancing quality of life.

• Listens to patients end-of-life wishes/desires and finds a hospice that is aligned with their values, preferences and needs.

• Identifies SDOH needs and effectively utilizes community resources to meet the identified needs of patients/families.

• Facilitates patient access to community resources as appropriate or refers to Care Navigator.

• Maintains documentation on EoL care managed population. Maintains accurate and timely documentation in the EMR.

• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.

• Works collaboratively with the leadership team to improve EoL care delivery and navigation through the evaluation, development and enhancement of policy, procedures and processes.

Minimum Qualifications:

• Active, unrestricted Florida nursing license

• Minimum of 3 years of professional level medical experience; experience in care coordination preferred.

• Experience working with patients with advanced serious illness; end-of-life care experience a plus.

Desired Qualifications:

• Ability to work collaboratively with people of diverse cultures and lifestyles.

• Ability to communicate and collaborate effectively with providers and medical staff.

• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.

• Ability to be self-motivating and work independently.

• Excellent communication and problem solving skills.

Guaranteed is a proud Equal Opportunity Employer. We recruit, train, and compensate our team members based on their qualifications. We want to hear from you regardless of your race, religion, national origin, sex, gender identity, sexual orientation, disability, age, veteran status, or any other applicable legally protected characteristics.

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