Registered Nurse - CA

Young Adult Institute; Town of Carson (WI); On-site; USD 74,000 - 105,000; Full time

Job summary

Young Adult Institute seeks a Registered Nurse to provide nursing services within assigned programs, collaborating with support staff and leadership. The role involves assessing health needs, documenting in EMR, and coordinating with medical providers.

The ideal candidate has an active California RN license and BLS certification, plus 2 years of nursing experience with I/DD or mental health cases. Ultrasensitive HIPAA adherence is required.

Qualifications

• Current active license as a Registered Nurse issued by the State of California Board of Registered Nursing;
• Current Basic Life Support (BLS) certification for Healthcare Providers;
• Two years of professional nursing duties experience with I/DD, mental health or related needs;
• Demonstrates sound clinical judgment in selecting methods to resolve med-related cases.

Responsibilities

• Provide nursing services in collaboration with direct support staff and program leadership.
• Collect data for assessments including vital signs and health history.
• Alert appropriate physicians to life-threatening or notable conditions and document actions.
• Document calls and encounters in EMR or paper per regulations and timelines.
• Educate on treatments, medications, diets, and health care plans with medical providers as needed.
• Train direct care staff on medical needs and eMAR processes.
• Coordinate with external providers to arrange appointments and trainings.
• Adhere to HIPAA and other regulatory requirements in all documentation.

Skills

Registered Nurse

BLS Certification

Vital Signs

Clinical Nursing

HIPAA

Education

RN License

Job description

Key/Essential Functions & Responsibilities

• Responsible for provision of nursing services for persons supported in assigned program(s), working in collaboration with direct support staff and program leadership to obtain information or updates on persons supported and reporting on-site for observations and assessments or to conduct trainings, as needed.
• Collects data to support assessments of persons supported including taking vital signs, social history, chief complaint(s) and current concerns.
• Alerts appropriate community physician to any complaints received by persons supported, especially those that are or may be life threatening, or otherwise notable.
• Documents all calls, correspondence and encounters with people we support in accordance with established guidelines and within appropriate timelines in electronic systems or on paper, as required by regulations.
• Utilizes the nursing process, assessing the condition and learning needs of persons supported as it relates to their health care and provides education regarding treatments, special diets, medications, follow-up diagnostic tests and healthy lifestyle information, in collaboration with medical providers, if needed.
• Triages emergency and non-emergency phone calls from program staff, leadership and/or persons supported during and outside of regular working hours and recommends appropriate actions or destinations (e.g. Urgent Care, Emergency Room etc.), documenting according to protocols.
• Observes, records and reports patient's condition and reaction to drugs and treatments to psychiatrist, external or other community medical providers.
• Develops and maintains an understanding of Titles 17 and 22 as they relate to medical needs/care and of specific medical and related conditions of the persons supported in assigned programs.
• Writes, reviews and/or updates individualized nursing health care and restricted health care plans for persons supported in assigned program(s); completes reports, forms and/or other summary documents as required.
• Presents information and responds to questions from IITS Multidisciplinary team, YAI and community providers regarding health, conditions and/or status of persons supported in assigned program(s) in regularly recurring meetings or as needed or requested.
• Follows established protocols to document, update or forward diagnostic tests, as directed or requested by medical providers.
• Reviews medical records including diagnostic tests and labs or other pertinent information and takes appropriate action to address health, wellness or medical concerns and escalates to appropriate medical providers, when needed.
• Documents and reports clinical information or complaints regarding care or incidents with staff or providers in community settings (e.g. urgent care, ER, psychiatric wards) received from external entities or direct support staff to the physician in accordance with applicable regulations; interfaces with external providers, hospitals, clinics, etc. when needed to coordinate care or address concerns.
• Regularly trains all direct care staff and management at assigned program(s) regarding individual medical needs, including medication information, administration and electronic medical administration record (eMAR), chronic or other conditions and/or specific nursing health care or restricted health care plans for each person supported.
• Participates in intake assessments during the referral process, reviewing medical records and documentation, performing direct observations and/or assessments with the individual, as requested.
• Interfaces with the external consultants and community providers (e.g., Psychologists, Psychiatrists, NPs, Physicians, etc.) to collaborate regarding the medical needs of the people YAI supports, including coordinating appointments, trainings, assessments, updates and observations.
• Complies with all Federal, State, Local and other relevant regulatory agency requirements, including the Health Insurance Portability and Accountability Act (HIPAA).
• Completes and maintains all necessary trainings based on program and position to ensure compliance with YAI policies and licensing regulations and applies skills.
• Performs all other duties as assigned.

Pay Rate: $65.00 Per Hour

Minimum Qualification Requirements including education, experience, licensure/certification, etc. and essential physical capabilities (e.g. lifting, assisting lifting, standing, etc.)

• Current active license as a Registered Nurse issued by the State of California Board of Registered Nursing;
• Current Basic Life Support (BLS) certification for Healthcare Providers;
• Two (2) years of experience performing professional nursing duties in any setting including experience with individuals with I/DD, mental health or related needs and/or individuals in crisis;
• Demonstrates sound clinical judgment in selecting methods and techniques to resolve med