Home Health Admission RN

Canyon Home Care & Hospice LLC•Ogden, UT

3d•Onsite

About The Position

A Registered Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Clinical Manager. The Home Health Admission Registered Nurse (RN) is responsible for completing comprehensive initial evaluations and admissions for patients referred to home health services. The Admission RN assesses the patient’s clinical needs, homebound status, eligibility for services, medication and disease management needs, safety concerns, and support system while developing an individualized plan of care in collaboration with the patient, family, physician, and interdisciplinary team. The Admission RN plays a critical role in establishing a strong foundation for the patient’s episode of care through thorough assessment, accurate documentation, timely communication, and appropriate coordination of services.

Requirements

Graduate of an approved school of professional nursing and currently licensed in the state(s) in which practicing.
Current, unrestricted Registered Nurse (RN) license in the state of practice.
Graduate of an accredited nursing program.
Current CPR/BLS certification.
Acceptance of philosophy and goals of this Agency.
Ability to exercise initiative and independent judgment.
Strong clinical assessment and critical-thinking skills.
Excellent written and verbal communication skills.
Ability to work independently and make appropriate clinical decisions in the home setting.
Strong organizational and time-management skills.
Reliable transportation and ability to travel to patients’ homes.
Ability to effectively use electronic medical records and required technology.

Nice To Haves

One (1) year nursing experience, preferred.
Previous home health experience preferred.
OASIS experience preferred.

Responsibilities

Complete comprehensive Start of Care (SOC) assessments and admission visits in the patient’s home.
Assess the patient’s medical condition, functional status, safety, psychosocial needs, medications, environment, and available support system.
Determine and document homebound status and the patient’s need for skilled home health services.
Evaluate the patient’s eligibility and appropriateness for home health services.
Identify the patient’s primary diagnoses and the most clinically pertinent conditions affecting the need for home health.
Develop an individualized plan of care based on the patient’s assessment findings, physician orders, and identified skilled needs.
Determine appropriate disciplines needed, including nursing, physical therapy, occupational therapy, speech therapy, medical social work, and home health aide services.
Coordinate the admission and plan of care with physicians, providers, therapists, caregivers, and other members of the interdisciplinary team.
Obtain and document appropriate physician orders and communicate changes or concerns to the provider in a timely manner.
Complete all required OASIS, SOC, medication reconciliation, and admission documentation accurately and within agency timeframes.
Clearly document the patient’s skilled needs, clinical findings, interventions, goals, risks, and anticipated outcomes.
Provide patient and caregiver education regarding medications, disease processes, safety, infection prevention, emergency procedures, and the plan of care.
Identify potential risks, including falls, medication issues, infection, hospitalization, nutritional concerns, skin breakdown, and other changes in condition.
Communicate significant assessment findings and concerns promptly to the appropriate provider and interdisciplinary team members.
Ensure all admission documentation supports medical necessity and clearly demonstrates why skilled home health services are required.
Participate in care coordination and assist with ensuring a smooth transition from referral/admission to ongoing case management.
Follow agency policies, Medicare/Medicaid requirements, applicable state and federal regulations, and professional nursing standards.
Maintain patient confidentiality and comply with HIPAA requirements.
Respond appropriately and professionally to patient, caregiver, physician, and team communication.
Participate in ongoing education, competency requirements, quality improvement initiatives, and agency meetings as required.
Monitor assigned admission referrals and agency communication systems for new admissions.
Contact patients/caregivers in a timely manner to coordinate the admission visit.
Complete admissions within established agency scheduling expectations.
Review available referral information, physician documentation, diagnoses, medications, and insurance requirements prior to the admission when possible.
Ensure the patient and caregiver understand the purpose of home health and the services being provided.
Communicate admission information and pertinent findings to the appropriate members of the care team following the admission.
Complete required admission communication templates and documentation according to agency standards.
Close and submit documentation within established agency timeframes, preferably within 24 hours and no later than the agency's required timeframe.
Maintain an efficient admission schedule while ensuring thorough, high-quality patient assessments.
Manage multiple admissions while prioritizing patient safety, clinical appropriateness, and timely documentation.
Demonstrate strong time-management and organizational skills.
Communicate proactively regarding scheduling barriers, referral concerns, or changes that may affect admission capacity.
Work collaboratively with the scheduling and clinical leadership teams to maintain appropriate admission coverage and patient continuity.