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/or related EMR information. The RN analyzes this data to determine issues and available resources for effective resolution. A key aspect of the role is 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 frequency of services, mitigate risk, and ensure high-quality outcomes. The position requires prioritizing multi-issue situations based on criticality, patient/staff safety, and impact on services. The RN will identify barriers to resolution (e.g., language, literacy, psychological) and follow up with appropriate resources or leadership. A plan of care will be developed and overseen, ensuring effective communication and supporting quality patient outcomes and satisfaction. The RN will implement the plan, direct care coordination with a multidisciplinary team, and supervise LPNs and/or HHAs. Ordered treatments, therapies, and/or procedures will be performed in accordance with relevant regulations and policies. Progress towards patient-centered goals will be evaluated.
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Job Type
Full-time
Career Level
Mid Level