Registered Nurse - Care at Home

Central Health•Austin, TX

About The Position

Under the supervision of the Director of Case Management, the Care at Home Registered Nurse is part of a collaborative, multidisciplinary team supporting clients in the Care at Home Program. The program provides temporary healthcare services to people discharging from acute care facilities, including hospitals and skilled nursing facilities. The RN reviews incoming referrals for appropriate placement and confirms that admission criteria are met. In collaboration with an Advanced Practice Provider, the RN provides general nursing care as defined by the Texas Board of Nursing. The role is part of the Transitions of Care team and works closely with Case Management, Medical Respite, and Post-Acute Care teams.

Requirements

Associate’s degree and graduation from an accredited school of nursing.
Three years of clinical experience in an ambulatory care setting, hospital setting, home health, or community agency.
Three years of experience managing populations with complex medical needs.
Unrestricted Registered Nurse license in Texas or compact-state licensure.
Basic Life Support (BLS) certification obtained through the American Heart Association or Red Cross.
Ability to work with people from diverse socioeconomic backgrounds.
Sound critical-thinking and decision-making skills.
Skill in triage and determining an appropriate level of care accurately and efficiently.
Effective interpersonal skills and ability to work with an interdisciplinary care team.
Ability to plan, organize, develop, implement, and interpret programs, goals, objectives, policies, and procedures needed to provide quality care.
Strong written and oral communication skills.
Ability to relate positively, favorably, and cooperatively with employees, patients, family members, and personnel from outside agencies and organizations.
Familiarity with tools, technology, and systems commonly used in healthcare environments, including EHRs, personal computers, and Microsoft Office.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Two years of simple wound care experience.
One year of experience with EPIC.

Responsibilities

Assess discharge needs accurately; coordinate medications and appointments; document care; report to appropriate personnel; and collaborate with Advanced Practice Providers, primary care providers, specialists, and community providers.
Review medications against lists from the discharging provider or facility.
Work with hospitals, skilled nursing facilities, community clinics, and other programs to assess referrals against inclusion criteria, including traveling for in-person assessments when needed.
Accompany an Advanced Practice Provider on home visits and complete intake assessments in the Electronic Health Record.
Delegate appropriate tasks to Medical Assistants and Community Health Workers.
Provide direct nursing care and education in clients’ homes, ensuring their needs are met in accordance with established policies and procedures.
Complete daily and weekly quality assurance checklists, including delegation of tasks to staff as appropriate (McKesson, CLIA, etc.).
Assist with oversight of infection control standards.
Participate in continuous quality improvement projects to improve service quality for patients, families, and the healthcare system.
Support organizational initiatives that promote and maintain a positive workplace culture.
Triage incoming Care at Home referrals and ensure admissions meet defined program criteria.
Ensure client care tasks, administrative processes, and related duties comply with regulatory and accreditation standards and Central Health procedures and policies.