Home Health RN On-Call Nurse

Bienvivir All-Inclusive Senior Health • El Paso, TX

7d • $37 - $55 • Hybrid

About The Position

Bienvivir All-Inclusive Senior Health (“Bienvivir”) is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly (“PACE”). PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.

Requirements

• A graduate from an approved professional accredited school of nursing, licensed to practice in the State of Texas.
• Currently licensed (in good standing) through the State Board of Texas as a registered nurse.
• Have at least one year experience as an RN obtained within the last 36 months.
• Experience in triaging the frail elderly in either a hospital, clinic, or home health setting.
• Current CPR card.
• Current TB test and/or chest X-ray.
• Must have reliable transportation, valid driver license and current insurance.

Nice To Haves

• Over 2 years’ experience in Home Health and/ or PACE setting preferred.

Responsibilities

• Be available via telephone to receive and prioritize calls from BSHS telephone answering system and to follow up with participants’ medical needs and concerns.
• Monitor and retrieve voicemail messages during assigned on-call hours. Return calls in a timely and professional manner. Coordinate with nurse triage line, providers, or emergency services as needed. Triage participant concerns based on clinical urgency; providing clinical guidance based on scope of practice.
• Manages after-hours communication related to participant emergency room visits, hospital admissions, and discharges. Responsibilities include notifying providers and the interdisciplinary team, coordinating and reviewing discharge orders, communicating care needs to facilities or caregivers.
• Work in coordination with other after-hours on-call staff via phone to address participant medical needs and arranging urgent medications, DME, or services.
• Communicate effectively with participants, caregivers, and designated representatives to coordinate care and respond to clinical concerns and phone calls promptly.
• Maintains communication regarding participant’s care with the Provider, HH Nursing Supervisor, and family, as appropriate.
• Provides a comprehensive end-of-shift email report to support continuity of care, detailing all interventions and resolutions rendered.
• Performs Skilled Nursing visits in participants’ private residences, assisted living facilities, and other approved locations for Bienvivir participants.
• Provides nursing interventions according to the participants plan of care
• Administers medications and treatments per provider orders.
• Facilitates transitions of care and supports continuity across settings, including hospital, skilled nursing facility, and home transitions.
• Observes participants for changes in condition and promptly reports findings to the provider and/or designee.
• Completes Start-of-Care, routine, and as-needed nursing assessments, including evaluation of medication compliance, symptom burden, functional status, changes in condition and death assessments within 24 hours of participant encounter.
• Completes reassessments promptly at the request of the participant, designated representative or on-call MD/NP, with urgency determined by clinical severity, during shift.
• Documents all assessment findings accurately and timely in the medical record within 24 hours of participant encounter.
• Performs death assessment and pronouncement if appropriate, following organization policies and Texas Health and Safety Code.
• Implements evidence-based interventions for participants with advanced illness and chronic disease.
• Monitors disease progression and symptom trends through ongoing assessments and telephone follow-ups with participants and/or caregivers, adjusting care proactively as needed.
• Supports chronic disease management within a comfort-focused plan of care, prioritizing symptom relief and minimizing burdensome interventions.
• Collaborates closely with Comfort Care providers to recommend medication adjustments, alternative therapies, and supportive measures consistent with participant goals.
• Ensure all assessments, interventions, communications, and participant responses are documented accurately and timely in the medical record.
• Provides ongoing education to participants and caregivers regarding disease processes, anticipated progression, and comfort-focused care expectations.
• Educates participants and caregivers on medication purpose, administration, potential side effects, and end-of-life comfort medications.
• Instructs on symptom monitoring, comfort measures, safety practices, and effective self-management strategies.
• Reinforces Comfort Care Program education in a culturally sensitive, participant-centered manner.
• Provides emotional support to participants and caregivers, addressing coping, comfort, and care-related concerns.
• Identifies risk factors and initiates preventive interventions aligned with comfort care principles.
• Implement strategies to prevent avoidable hospitalizations and emergency department visits.
• Prevents complications such as skin breakdown, falls, medication errors, and unmanaged symptoms.
• Monitors and promotes skin integrity, nutrition, hydration, and mobility within participant tolerance and goals of care.
• Documents all assessments, interventions, education, communications, and participant responses accurately within 24 hours of encounter.
• Ensures documentation reflects skilled nursing services, medical necessity, and alignment with the established plan of care.
• Maintains compliance with HHSC requirements and nursing practice standards.
• Ensures coordination of 24-hour service delivery.
• Maintains ongoing communication with the Home Health Nursing Supervisor and/or Administrator regarding participant status, care delivery, and problem resolution.
• Escalates clinical concerns, changes in condition, and safety issues promptly.
• Participates in holiday and assigned on-call rotations, providing telephone triage, addressing family and caregiver concerns, and conducting home visits as clinically indicated.
• Attend Home Health meetings, in-person and online in-services, and mandatory training.
• Audits Skilled Nursing and Comfort Care visit documentation on a weekly basis and maintains the QA spreadsheet to ensure compliance with Texas Health and Human Services Commission (HHSC) requirements.
• Notifies staff of audit findings and provides guidance on required documentation corrections, as indicated.
• Participate in competency assessments and performance monitoring.
• Participate in professional organizations and continuing education activities, when appropriate.
• Performs other duties as assigned by the Home Health Nursing Supervisor or HH Administrator.
• Protects participant confidentiality in accordance with HIPAA.

Benefits

• We pay 100% of the MEDICAL monthly premiums for Employee Only coverage.
• We pay 100% of the DENTAL monthly premiums for Employee Only coverage.
• We provide an affordable VISION monthly premium for Employee + Family coverage.
• We pay 100% of BASIC LIFE for a benefit amount of $10,000.
• We offer safe harbor matching contributions for the 403(B) RETIREMENT SAVINGS account.
• We offer up to fifteen (15) days of PAID TIME OFF based on paid hours per pay period.
• We offer eleven (11) company-observed PAID HOLIDAYS.
• We offer education and TUITION REIMBURSEMENT.
• We offer MILEAGE REIMBURSEMENT.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level