The position is responsible for the managing and providing skilled nursing care to patients.

Ensures the efficient delivery of home health skilled nursing services while at a minimum adhering to state and federal laws, state and federal rules, accrediting body standards, accepted discipline practices, ethical standards, agency policies and procedures, the agency?s mission and values, the agency?s code of conduct, and business decorum.

Conducts admission visits.

• Identifies self as a representative of the agency to patients/clients and their families at the start of admission visits.
• Ensures patients are adequately educated on home health in general and on the specific care they will receive while under a home health plan of care.
• Ensures the accurate completion of all admission visit documents in a timely manner.
• Ensures the accurate documentation of admission visits in a timely manner.
• Independently identifies educational needs of patients/clients and their families related to patients?/clients? specific care needs and ensures patients/clients and their families are timely and adequately educated.
• Develops a plan of care to address patients/clients specific care needs.

Manages patient/client care pursuant to the established plan of care and conducts visits.

• Accurately completes weekly schedule and conducts visits ensuring compliance with established visit frequencies.
• Identifies self as a representative of the agency to patients/clients and their families at the start of visits, as necessary.
• Ensures the start and completion of visits are independently documented using telephony or other prescribed method.
• Identifies, recommends, documents and implements changes to the plan of care as approved by patients?/clients? physicians in a timely manner.
• Ensures the accurate and efficient procurement of medical supplies in a timely manner.
• Works to maximize patient/client outcomes.
• Exemplifies and promotes positive, professional, and effective communication between and among disciplines. Ensures report is given to all disciplines involved in care prior to their initial visits and report is given and received prior to past visits made by a non-case managing nurse.
• Acts as the point of contact for patients/clients, their families, caregivers, and physicians.
• Conducts Home Health Aide supervisory visits, as required by law and agency policy.
• Ensures the accurate completion of all visit documents in a timely manner.
• Ensures the accurate documentation of visits in a timely manner.

Prepares patients for discharge and conducts discharge visits.

• Notifies patients/clients of pending discharge in a timely manner.
• Conducts discharge visits.
• Ensures the accurate completion of all discharge visit documents in a timely manner.
• Ensures the accurate documentation of discharge visits in a timely manner.

Attends and participates in meetings and activities to effect quality and performance improvement.

• Ensures competencies are completed in a timely manner.
• Participates in agency sponsored continuing education opportunities.
• With supervisor, identifies continuing education opportunities to improve job-related knowledge and skills.
• Takes an active role in learning changes to state and federal laws, state and federal rules, accrediting body standards, accepted nursing practices, ethical standards, agency policies and procedures, the agency?s mission and values, the agency?s code of conduct, and business decorum.
• Takes an active role in learning existing, new, and updates to technology utilized by the agency, including but not limited to patient/client care software, telehealth, and the Microsoft office suite.
• Attends and participates in various meetings, including but not limited to nurses meetings, case conferences, staff meetings, and disease management meetings.

Effectively represents the agency in a professional manner.

Communicates significant events and other data necessary for timely and accurate decision-making to the appropriate individuals.