Job Summary:
The Home Care Registered Nurse is responsible for providing skilled nursing care, case management, and patient education in a home care setting. This role involves assessing patient and caregiver needs, developing and implementing individualized care plans, managing caseloads, and ensuring compliance with state and federal regulations. The nurse collaborates with interdisciplinary teams to deliver high-quality, evidence-based care and maintains thorough and timely documentation including OASIS requirements. Proficiency in advanced nursing skills such as IV therapy, wound care, and infection control is essential.
Responsibilities:
- Assess patient and caregiver needs using the nursing process to deliver quality care in accordance with regulations and agency policies.
- Develop, communicate, and update realistic care plans involving patients and caregivers.
- Serve as Case Manager for assigned patients, managing caseloads and visit schedules to meet productivity standards.
- Complete OASIS documentation accurately and timely, staying current with documentation requirements.
- Implement medical plans of care and nursing interventions to ensure safe and effective treatment.
- Maintain and update skills in high-tech nursing procedures including IV use, wound VAC, and complex wound care.
- Collaborate with LPNs to delegate tasks and ensure adherence to care plans.
- Evaluate patient responses and care outcomes, adjusting plans as necessary to ensure quality care.
- Maintain accurate and up-to-date nursing documentation to support continuity of care.
- Follow agency protocols for visit documentation and communication.
- Provide patient and caregiver education on medication, treatment options, discharge instructions, and reportable conditions.
- Identify and communicate interdisciplinary patient needs to appropriate team members.
- Complete required agency, state, and federal forms in a timely manner.
- Conduct visits efficiently and communicate scheduling needs to the scheduler.
- Assess and coordinate Home Care Aide services and supervise as required.
- Report patient incidents promptly to quality improvement specialists.
- Coordinate safe patient discharges and transfers with proper documentation.
- Collaborate with physicians, providers, vendors, and team members to support care plans.
- Participate in monthly peer review audits and provide constructive feedback.
- Schedule and facilitate case conferences to enhance team communication and document outcomes.
- Advocate proactively for patient care needs to ensure sensitive and appropriate services.
Required Skills & Certifications:
- Active Registered Nurse license in the state of practice.
- Minimum of 2 years of nursing experience, preferably in home health, hospice, or hospital settings.
- Proficiency in OASIS documentation and home care nursing regulations.
- Strong clinical assessment, medication administration, and treatment planning skills.
- Excellent communication and interdisciplinary team collaboration skills.
- Valid driver's license, car insurance, and reliable automobile for field work.
- Bachelor's degree in Nursing or related field.
Preferred Skills & Certifications:
- Experience with high-tech nursing skills such as IV therapy, wound VAC, and complex wound care.
- Knowledge of infection control standards and advanced nursing procedures.
- Experience in case management and coordinating interdisciplinary care.
Special Considerations:
- Must comply with state and federal home health care regulations and agency policies.
- Ability to work independently in a home care environment.
- Occasional on-call or flexible scheduling may be required based on patient needs.
- Must maintain confidentiality and adhere to professional nursing standards.
Scheduling:
- Work schedule typically involves visiting patients in their homes during regular business hours.
- Visit times and caseloads are managed to meet agency productivity standards.
- Coordination with scheduler to ensure timely and efficient visit planning.