Employment Type: Full time Shift: Description: Position Purpose: Our Home Care RNs (Primary Care Nurses) provides primary nursing care to home based care patients as ordered by the physician, and in accordance to the organization’s policies and procedures. The RN is responsible for the initial assessment and care plan development in collaboration with the Population Health Case Manager. Provides functional support/supervision to Home Healthcare Aides and LPNs as needed. Provides therapeutic intervention, overall care management and achievement of top decile client outcomes and patient satisfaction. What You Will Do: Accurately assesses patient condition and risk at admission, at required time points, and as needed, utilizing appropriate standardized documentation. Assesses the patient's condition and needs and determines the appropriate level of care. In collaboration with the physician, Population Health Case Manager, and patient, develops appropriate assessment-based plan of care including: attainable patient goals and services needed to improve and/or stabilize patient’s medical condition, functional abilities and promote independence. Maintains a current working knowledge of applicable Federal, State, and local laws and regulations, the Organizational Integrity Program, Code of Ethics, as well as agency policies and procedures and follows Code of Conduct. Reports changes in patient condition in a timely manner to the physician and/or Population Health Case Manager. Obtains orders for changes in the plan of care to respond to the patient's condition. Follows orders for treatment and provides services as indicated on the plan of care. Utilizes and implements appropriate educational tools and pathways per guidelines and/or policy and procedure. Takes ownership to optimize agency performance through active involvement in quality improvement activities. Provides ongoing care management oversight/activities to assigned patients to achieve high quality care, reduced rehospitalizations and achievement of top decile outcomes. Utilizes motivational interviewing/health coaching techniques to achieve desired patient outcomes. Accurately documents and submits timely the assessment, interventions and evaluations pertaining to patient's care management and services in accordance with the agency policy and procedure. Adjusts weekly, monthly patient visit schedule to achieve care consistency, visit utilization ordered and operational efficiencies, avoiding duplication, interruption or overlap in visits. Communicates with Clinical Manager, timely, if identifies need for additional visits at identified time points. Provides written documentation regarding changes in patient's condition/situation requiring potential need for changes service utilization. Initiates, maintains and documents communication regarding the client’s care/needs with the physician, clinical manager, other disciplines, and family, as appropriate. Demonstrates self-education as evidenced by completion of mandatory annual trainings and continuing educational opportunities. Demonstrates furthering professional growth through sharing knowledge with others. Acts independently and responsibly to perform duties on a consistent basis and in a timely manner. Benefits: Work Today Get Paid Tomorrow Employee Referral Reward Program Mileage reimbursement Comprehensive orientation Minimum Qualifications: Graduate of an approved Nursing education program, BSN preferred. Current Registered Nurse licensure in the state of practice. Must have a minimum of one (1) year professional nursing experience. Med-Surg, ER, Urgent Care, ICU, Critical Care, Progressive Care, or Step-Down Unit experience Home healthcare experience preferred. Strong computer and technology skills required. Must have current Driver’s license and reliable transportation. Position Highlights: We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. We live and breathe our guiding behaviors: we support each other in serving, we communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners. Ministry/Facility Information: Trinity Health At Home is shaping the future of healthcare. Our standard, evidence-backed care models and operations are enhancing our colleagues' experience, empowering families, and delivering better care at lower costs. We use the industry's best technology, including: Lightweight tablets Advanced, easy-to-use EMR Messaging and communication tools Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.