This position is responsible for the daily management of an assigned patient caseload, ensuring timely care and documentation to meet patient needs and services as prescribed in the established plan of care and per MD orders. The role involves collecting data pertinent to the healthcare consumer's health or situation from patient assessments in the home setting, telephonic contacts, and EMR information. The nurse will analyze this data to determine issues and available resources for resolution, identify patients at high risk for re-hospitalization, falls, or high utilization of resources, and implement interventions. Prioritization of multi-issue situations based on criticality, patient/staff safety, and timely services is essential. The role also involves identifying and addressing barriers to resolution, developing and overseeing a plan of care, and implementing it while directing care coordination with a multidisciplinary team, including supervision of LPNs and HHAs. Performing ordered treatments, therapies, and procedures, and evaluating progress towards patient-centered goals are also key functions.
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Job Type
Full-time
Career Level
Mid Level