Chapters Health System Benefits Overview

Provide nursing case management for PACE participants: assess needs, coordinate individualized plans of care with the interdisciplinary team, perform home visits, deliver clinical/palliative/supportive care, document in EMR, obtain physician orders, supervise aides, and participate in IDT meetings to help participants remain safely at home.

Develops hospital and healthcare referral relationships to increase patient referrals and admissions. Manages assigned territories, conducts more than 50 weekly sales calls, creates quarterly sales plans, develops new referral sources, provides education and updates, documents activity in CRM, and resolves account concerns. The role requires extensive customer-facing travel, strong communication and public speaking skills, independent judgment, and achievement of territory growth and admission goals.

Coordinates and implements homecare services for frail elderly PACE participants. Assesses needs, develops care plans, coordinates agencies, staffing, durable medical equipment, supplies, environmental adaptations, and service delivery. Maintains patient data, reports, invoices, and requisitions; participates in interdisciplinary team meetings; conducts agency audits and home visits; and provides customer service to patients, families, caregivers, vendors, and healthcare staff.