The Opportunity

Primary functions are to administer skilled nursing care for patients/clients of all ages in their place of residence, coordination of care with the interdisciplinary team, patient/client, family and referring agency. Assumes the responsibility for and participates in the coordination of care.

Provide Care

• Completes initial and ongoing assessments to identify the physical, psychosocial and environmental needs of home health patients/clients. Completes assessments at appropriate time points, including Outcome and Assessment Information Set (OASIS) or other assessments as appropriate to the patient/client.
• Regularly re-evaluates the patient’s/client’s nursing needs and evaluates the outcomes of care.
• Develops, initiates and revises the plan of care in partnership with the patient/client, representative (if any) and caregiver(s) as necessary to ensure quality and continuity of care. Initiates appropriate preventative and rehabilitative nursing procedures. Refers to other services as needed. Provides patient/client and caregiver education. Plans for the discharge of the patient/client from services.
• Furnishes those services requiring substantial and specialized nursing skill that are ordered by the physician as indicated in the plan of care. Counsels the patient/client, caregiver and family in meeting nursing and related needs. Uses infection control measures that protect both staff and patient/client.
• Coordinates services. Informs the physician and other personnel of changes in the patient’s/client’s condition and needs. Communicates with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care. Integrates orders from all relevant physicians involved into the plan of care and ensures the orders are approved by the responsible physician.
• Monitors assigned cases to ensure compliance with requirements of third party payors.
• Prepares clinical and progress notes. Completes appropriate documentation in a timely manner.
• Demonstrates commitment and professional growth by participating in Agency-sponsored in-service programs and maintaining or improving competency. Participates in the Agency’s QAPI program.
• Supervises, teaches and provides clinical direction to other nursing personnel. Assigns home health aides to specific patients/clients. Supervises LPNs/LVNs and paraprofessionals providing services to patients/clients. May conduct aide competency evaluations if qualified with two years of clinical experience and one year of home health experience.
• Promotes Agency philosophy and administrative policies.
• Performs on-call responsibilities and provides on-call services to patients/clients and their families as assigned.
• Provides effective communication to the patient/client, family, team members and other health care professionals.

Communicate

• Contributing to and setting up residents’ care plans
• Provide emotional support, consult, and to serve as a source of comfort for residents and their loved ones
• Partner with, and improve working relationships, with doctors and healthcare providers
• Recognize abnormal changes in body functioning and report to a supervisor

What You’ll Bring

Experience & Education

• Associates degree or higher, focused on advancement into medical services, or similar, preferred
• 3-5 years of Public Health experience with completion or readiness to apply for a certification administered by the National Board of Public Health Examiners, preferred
• CPR/First Aid Certification desired (unless required by the State)
• Previous experience in long-term care preferred
• Valid, unrestricted Registered Nurse Licensure required

Engagement

• Working experience alone, on a team, and on projects start to finish
• Strong emotional intelligence and listening skills
• Dedication to the medical field, especially towards working with the residents