Are you Overwhelmed at work? Are you tired of night shifts? 

Major Areas of Responsibilities:

Patient and Family Educator: Educates the patient and family on the disease process. Promotes and maintains patient health and independence through teaching and appropriate rehabilitative measures, while assisting patients in learning appropriate self-care techniques. Advocates for patients and ensures participation in care planning and goals of care.

Plan of Care: Assists patients through managing their Plan of Care and observes and monitors their conditions and perform necessary assessments. Performs patient comprehensive assessments and collaborates with patient multi-disciplinary care team (PT, OT, ST, MSW, and paraprofessionals) to develop, modify, and implement an individualized patient plan of care, per physician orders that ensure quality treatment, proper discharge planning, and achieves desired outcomes and goals.

Collaboration: Helps to achieve and maintain continuity of patient care by communicating information, including changes in the plan of care, new orders, lab results, and new referrals promptly. Engages other care team members when necessary to achieve desired patient outcomes. Facilitates interdisciplinary communication and follow-up through care coordination. Participates in team meetings and case conferences and leads discussions on multidisciplinary cases as appropriate. Maintains ongoing communication with a clinical manager regarding the progress of patients for assigned caseload.

Requirements

• Registered Nurse License in the State of Virginia OR Compact License 

• Prior Home Care experience OR strong clinical background 

• Prior EMR experience (Kinsser preferred)

• MUST be efficient with documentation