Job Description

This position serves as a liaison and advocate for resident clients.

Schedule: Monday- Friday 40 hours/ week with on call rotation.

DUTIES/RESPONSIBILITIES

1. Manage all aspects of resident client’s care needs.
2. Communicates with residents, physicians, families, and care partners.
3. Attends physician appointments with resident.
4. Reviews health insurance policies and other non-financial information as directed by resident clients.
5. Provides crisis intervention (i.e. ER visits, hospital stays).
6. Acts as a resident client advocate.
7. Coordination and supervision of supportive services
8. Ensures that the professional standards of community nursing are maintained.
9. Adhere to Plymouth Harbor’s procedures and resident care policy.
10. Write a short plan of care for each resident and execute that plan.
11. Assure progress reports are made to all Physicians, and residents’ families
12. Ensure that residents’ confidentiality is maintained.
13. Ensure that care management is appropriate, adequate, and consistent with plan of care, medical regime, and residents’ needs.
14. Ensure that nursing and other services provided to the resident are coordinated, appropriate, adequate, and consistent with the plan of care.
15. Ensure that all service outcomes are completely legibly documented, dated, signed in the clinical record.
16. Attend and participate in workshops, seminars, and mandatory in-services as approved.

SUPERVISORY RESPONSIBILITY

• This position has no supervisory responsibility.

QUALIFICATIONS

Education

• Must be a Registered Nurse in the state of Florida and meet the criteria as defined in section 400.462(10) of the Florida Statutes.

Experience

• Preferred 3-5 years’ experience in case management, disease management, home health care management, hospital nursing or intensive outpatient education and self-management support.

General:

• Comprehensive nursing assessment, problem identification and care plan development
• Disease Management
• Screening for developmental issues, depression, other psychological conditions, and frailty.
• Clinical system design and development
• Relationship building with residents, families, and health care providers
• Behavioral strategies including motivational interviewing and self-management support
• Documentation
• Organized and resourceful self-starter, strong ability to work in a team
• Excellent written, oral, and interpersonal communication skills
• Must have good organizational skills.
• Must be a detail-oriented person and able to perform duties with great accuracy on a daily basis.
• Must have excellent personal skills, demonstrating the ability to conduct oneself in a non-controversial style, a style that inspires the respect of others and promotes a sense of trust in the individual’s competence.
• Must have good communication skills, speaking, writing, and listening.
• Must be fluent in English.
• Must be proficient with Microsoft Office programs with emphasis on Excel, Outlook, PowerPoint, Publisher, and Word, with the ability to learn and use proprietary software as required.

CERTIFICATES/LICENSES/REGISTRATIONS

• Must be a Registered Nurse in the state of Florida and meet the criteria as defined in section 400.462(10) of the Florida Statutes.

PERSONAL REQUIREMENTS

• Support Plymouth Harbor’s mission, striving daily to ensure the best possible outcomes for the health and well-being of residents and staff.
• Maintain high personal standards for performance and encourage others to do the same.
• Must be able to get along with others and work as a team player.
• Maintain confidentiality in all Plymouth Harbor, resident, and team member matters.
• Use good judgement and make independent decisions when circumstances warrant such action.
• Work harmoniously with all persons residing in, employed by, or associated with, the organization.
• Be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people.