In-Home RN: Care Coordinator & Field Support

Flournoy Health System; Georgia; On-site; USD 70,000 - 88,000; Full time

Job summary

Flournoy Health Systems in Wayne County, GA seeks a Registered Nurse to provide clinical oversight and coordination of care for home-based clients. The RN will perform initial assessments, develop care plans, supervise LPNs and caregivers, and ensure regulatory and Medicaid compliance within the established Plan of Care.

The role involves field-based coverage when needed to maintain continuity of care and adapt to operational needs, while ensuring quality and safety standards are met.

Qualifications

• Current, active, and unencumbered Registered Nurse (RN) license to practice in the State of Georgia.
• Current Basic Life Support (BLS) certification.
• Demonstrated clinical competency in assessing and caring for medically fragile and/or complex-care individuals.
• Ability to complete comprehensive client assessments, identify changes in condition, and develop and maintain individualized Plans of Care.
• Ability to provide clinical supervision, direction, and education to LPNs, caregivers, clients, and families.
• Working knowledge of applicable home and community-based service programs, including SFC, Personal Support Services, GAPP, and other assigned programs.
• Valid driver's license, reliable transportation, and automobile insurance meeting applicable state and company requirements.
• Current TB screening.

Responsibilities

• Complete initial assessments and reassessments and maintain individualized Plans of Care for clients receiving SFC, Personal Support Services, GAPP, and other applicable services.
• Provide clinical supervision and guidance to LPNs and caregivers, including completion and validation of required caregiver skills competencies.
• Coordinate with the assigned operational team to establish and maintain supervisory and IDT visit schedules and ensure required visits are completed timely.
• Conduct required supervisory visits for skilled clients and additional complaint, follow-up, or unannounced visits when clinically appropriate.
• Review and sign off on clinical and care-delivery documentation to ensure services and tasks align with the established Plan of Care.
• Manage physician Plans of Treatment (POT), including obtaining, reviewing, updating, and coordinating required clinical orders and documentation.
• Monitor complex medical conditions, identify changes in condition, safety concerns, and unmet care needs, and coordinate appropriate clinical interventions.
• Communicate with physicians, case managers, families, LPNs, caregivers,operational teams and other providers to support continuity and coordination of care.
• Provide client and caregiver education regarding diagnoses, disease processes, medications, treatments, safety, and care needs.
• Ensure clinical services and documentation comply with applicable Medicaid, program, regulatory, HIPAA, and agency requirements.
• Provide direct, in-field nursing support and coverage as needed to address staffing shortages, maintain continuity of care, and meet client service needs, consistent with licensure, clinical competencies, and the established Plan of Care.

Skills

RN license GA

BLS certification

Clinical assessment

Care coordination

Supervision

Education

Bachelor’s Degree

Job description

Flournoy Health Systems in Wayne County, GA seeks a Registered Nurse to provide clinical oversight and coordination of care for home-based clients. The RN will perform initial assessments, develop care plans, supervise LPNs and caregivers, and ensure regulatory and Medicaid compliance within the established Plan of Care.

The role involves field-based coverage when needed to maintain continuity of care and adapt to operational needs, while ensuring quality and safety standards are met.