Registered Nurse - Care at Home

careers-centralhealth; Los Angeles (CA); On-site; USD 75,000 - 95,000; Full time

Job summary

Central Health is seeking a Care at Home Registered Nurse to support patients discharging from acute care, providing nursing care in home settings and coordinating with the Transitions of Care team. Under supervision of the Director of Case Management, you will review referrals, assess needs, and ensure admission criteria are met, traveling for in-person visits as needed.

Qualifications include an Associate Degree in Nursing, 3 years in ambulatory or home health, TX RN license, and BLS; EPIC

Qualifications

• Associate's degree in nursing required.
• Three years clinical experience in ambulatory, hospital, home health or community setting.
• Experience managing populations with complex medical needs preferable.
• Texas RN license with unencumbered state license and BLS.

Responsibilities

• Assess discharging needs and coordinate medications and appointments.
• Review medications against discharge plan and elevate issues as needed.
• Travel for in-person assessments when required and collaborate with providers.
• Attend home visits with Advanced Practice Provider and complete intake in EHR.
• Delegate tasks to Medical Assistant and Community Health Worker.
• Provide direct nursing care in patients' homes and ensure patient needs are met.
• Ensure compliance with regulatory standards and organizational procedures.
• Support quality improvement initiatives and maintain home health program standards.

Skills

Critical thinking

Triaging

Interdisciplinary teamwork

Documentation

Microsoft Office

EHR proficiency

Education

Associate's Degree RN

BSN (preferred)

Tools

EPIC

EHR

McKesson

Job description

Overview

Under the supervision of the Director of Case Management, the Care at Home Registered Nurse is an integral part of a collaborative, multidisciplinary team that will support the clients in the Care at Home Program. The Care at Home Program serves as a temporary bridge in providing healthcare services to individuals who are discharging from acute care facilities such as the hospital or Skilled Nursing Facilities. The main duties of the Care at Home RN will include the review all incoming referrals for appropriate placement to the program and ensure criteria for admission are met. In collaboration with the Advanced Practice Provider, provide general nursing care as needed as defined by the Texas Board of Nursing. The Care at Home Registered Nurse will be an integral part of the Transitions of Care team and will interact closely with Case Management, Medical Respite and Post - Acute Care teams.

Responsibilities

Essential Functions:

• Completing accurate assessment of discharging needs, coordinating medication and appointments and documentation, reporting to appropriate personnel as indicated and working collaboratively with Advanced Practice Providers, primary care providers, specialists, and community providers.
• Medication review against list from discharging provider and/or facility.
• Work closely and collaboratively with local hospitals, skilled nursing facilities, community clinics and other programs to review incoming referrals according to inclusion criteria. This will include traveling to do an in person assessment if needed.
• Accompany Advanced Practice Provider for home visits and complete intake assessment in Electronic Health Record.
• Delegate appropriate tasks to Medical Assistant and Community Health Worker.
• Provide direct nursing care and education to clients in their homes and ensure all needs of the patient are met, in coonformance with established policies and procedures.
• Complete daily/ weekly quality assurance checklists to include delegation of trasks as appropriate to staff (McKesson, CLIA, etc.)
• Assist with oversight of infection control standards.
• Participate in continuous quality improvement projects in order to better serve the patient-client, family and healthcare system to improve the quality of service provided.
• Support organizational initiatives to promote and maintain a strong positive workplace culture.
• Triage all incoming referral for Care at Home Program and ensure admittance to program as clearly defined in program criteria.
• Ensure all tasks provided and associated with client care, patient administrative processes and related duties comply with all regulatory and accreditation standards, and Central Health Standard Operating Procedures, Policies and Procedures.

Knowledge, Skills, and Abilities:

• Demonstrates the ability to work with people from diverse socio-economic backgrounds.
• Sound critical thinking and decision-making skills.
• Skill in triaging and ensuring appropriate level of care for a patient in an accurate and efficient manner.
• Effective interpersonal skills and the ability to work with an interdisciplinary care team.
• Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures that are necessary for providing quality care.
• Proven written and oral communication skills.
• Able to relate positively, favorably and cooperatively with others, including employees, patients, family members, and personnel of outside agencies and organizations.
• Demonstrated familiarity with tools, technology, and systems typically found within most health care environments, (i.e. EHR, personal computer skills, including Microsoft Office)

Qualifications

Minimum Requirements:

Education :

Associate's Degree - Graduate from an Accredited School of Nursing

Work Experience:

Three (3) years Clinical Experience in ambulatory care setting, hospital setting, home health or community agency.

Three (3) years Background in managing populations with complex medical needs.

Preferred Requirements:

Education:

Bachelor's Degree - Bachelor of Science Degree in Nursing (BSN)

Work Experience:

Two (2) years Simple Wound Care

One (1) year Experience with EPIC

Licenses and Certifications Requirements:

RN - Registered Nurse - State Licensure and/or Compact State Licensure: Unrestricted Registered Nurse License in the State of Texas

Basic Life Support (BLS) - obtained through approved American Heart Association or Red Cross