Registered Nurse (RN), Home Health

Job Summary

The Registered Nurse (RN) provides skilled nursing care to patients in their homes in compliance with Medicare Conditions of Participation, California home-health regulations, and agency policies. The RN performs comprehensive assessments, initiates and updates the plan of care, delivers direct clinical interventions, supervises home health aides, and coordinates care across the interdisciplinary team. The RN functions with clinical judgment, autonomy, and accountability while ensuring high-quality, patient-centered service.

Essential Job Functions / Responsibilities

Patient Care & Clinical Management

• Perform Initial Assessment/SOC to determine home-health eligibility, skilled need, and homebound status .
• Complete full physical assessment and clinical history; identify nursing diagnoses and patient needs.
• Develop an individualized Plan of Care (POC) with measurable goals, interventions, and timelines.
• Update and revise the POC based on patient status, physician orders, and ongoing assessments.
• Provide skilled nursing interventions including wound care, medication administration, IV therapy, disease management, and preventive/rehabilitative procedures.
• Educate patients and families on self-care, symptom control, medication management, and safety.
• Identify discharge planning needs early, collaborate with the care team, and implement transition plans .
• Act as Case Manager for assigned caseload; coordinate with PT/OT/ST/MSW/HHA to ensure continuity of care.
• Maintain timely SOC, ROC, Recertification, and Discharge documentation per CMS guidelines.
• Implement emergency procedures as needed and escalate clinical concerns promptly.

Documentation & Communication

• Complete clinical notes, assessments, and care-plan updates accurately and on time (preferably same day; no later than 24 hours).
• Submit 485/POC updates to the ordering physician every 60 days or when changes occur .
• Communicate critical changes in patient condition to the physician and Clinical Supervisor.
• Obtain, document, and implement physician orders promptly as required by regulation.
• Coordinate care with community resources, hospital discharge planners, and interdisciplinary personnel.
• Ensure all documentation meets Medicare, Medi-Cal, private insurance, accreditation, and agency standards.

Supervision & Additional Duties

• Instruct, supervise, and evaluate Home Health Aide services every 14 days per regulatory standards .
• Ensure equipment, supplies, and DME are available and appropriate for the patient's care needs.
• Participate in on-call rotations in accordance with agency policy.
• Maintain compliance with HIPAA, infection control, patient-safety standards, and agency policies.
• Participate in case conferences, QA/Performance Improvement activities, and mandatory trainings.
• Maintain professional boundaries and exemplary customer-service conduct with all patients and families.

Position Qualifications

• Current, unencumbered California RN license.
• Graduate of an accredited school of nursing .
• Current CPR certification.
• Valid California driver's license, reliable insured transportation, and ability to travel to patient homes.
• Minimum two (2) years of nursing experience preferred, with at least one (1) year in home health, public health, or acute care setting .
• Strong clinical assessment, critical-thinking, and problem-solving skills.
• Ability to work independently and prioritize competing demands.
• Ability to lift, position, transfer patients, and meet physical mobility demands as described in the original document .

Before we connect, take a few minutes to explore our website at www.ha-homecare.com — you'll get a feel for who we are and what we do. Be sure to check out the Careers page as well; it has the full job description for this role, plus a few other openings that might interest you or someone you know.