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 from patient assessments, telephonic contacts, and EMR information, analyzing this data to determine issues and available resources for resolution. It also includes identifying patients at high risk for re-hospitalization, falls, or high utilization of resources, requiring additional intervention and case conferencing to ensure appropriate care and mitigate risk for high-quality outcomes. The position requires prioritizing multi-issue situations based on criticality, patient/staff safety, and timely services. Additionally, it involves identifying barriers to resolution (e.g., language, literacy, psychological) and following up with appropriate resources or leadership. The RN will develop and oversee a plan of care, communicate it effectively, and implement it by directing the care coordination of a multidisciplinary clinical team, including supervising LPNs and HHAs. Progress towards patient-centered goals will be evaluated.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree