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Acts as a resource to employees by assisting with coordination of patient care planning and outcomes. Assists with patient scheduling for nursing visits and revisits. Schedules regular interdisciplinary team meetings on a weekly basis and assures collaboration between all disciplines to coordinate patient care planning. Educates employees on changes and/or on new material and assists with precepting new hires. Reviews quality and operational reports and data with the teams to improve patient financial and clinical outcomes. Assumes responsibility for caseloads consisting of patients in geographical/specialty areas. Conducts initial assessment to obtain thorough physical, social and environmental data. Establishes the plan of care in accordance with the physician orders and patient needs. Provides direct patient care and adjusts nursing care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate. Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated. Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines. Completes documentation including visit assessment, development of the POC, and verbal orders accurately and promptly and within the standards. Communicates with physicians to confirm and update patients' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team. Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
Job Responsibility:
Acts as a resource to employees by assisting with coordination of patient care planning and outcomes
Assists with patient scheduling for nursing visits and revisits
Schedules regular interdisciplinary team meetings on a weekly basis and assures collaboration between all disciplines to coordinate patient care planning
Educates employees on changes and/or on new material and assists with precepting new hires
Reviews quality and operational reports and data with the teams to improve patient financial and clinical outcomes
Assumes responsibility for caseloads consisting of patients in geographical/specialty areas
Conducts initial assessment to obtain thorough physical, social and environmental data
Establishes the plan of care in accordance with the physician orders and patient needs
Provides direct patient care and adjusts nursing care processes as needed
Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame
Advises and consults with family and other personnel, as appropriate
Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate
Updates and revises plan of care as indicated
Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines
Completes documentation including visit assessment, development of the POC, and verbal orders accurately and promptly and within the standards
Communicates with physicians to confirm and update patients' plan of care
Provides status updates and ensures ongoing communication with the physician and other members of the health care team
Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge
Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate
Participates in chart audits and continuous quality improvement activities as requested
Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served
Requirements:
Nurse, Registered (RN) license
A valid driver’s license issued by the Division of Motor Vehicles
Bachelor's Degree in Nursing
5 years of experience in clinical nursing
Advanced clinical and technical knowledge of home care
Excellent communication skills
Strong interpersonal skills
Good organizational, analytical and problem-solving skills
Proficiency in clinical skills
Ability to operate necessary equipment (FAX, computer, copier, telephone system)
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA)
Ability to lift up to 35 pounds
Ability to travel to all areas within the service area in all extremes of weather
Willingness to work occasional overtime
What we offer:
Paid Time Off programs
Health and welfare benefits (medical, dental, vision, life, Short- and Long-Term Disability)
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits (adoption assistance and paid parental leave)
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call
Incentive pay for select positions
Opportunity for annual increases based on performance