Registered Nurse - Care at Home

Central Health•Austin, TX

About The Position

The Care at Home Registered Nurse is part of a collaborative, multidisciplinary team supporting clients in the Care at Home Program. The program temporarily bridges healthcare services for people discharged from acute care facilities, including hospitals and skilled nursing facilities. Under the supervision of the Director of Case Management, the RN reviews incoming referrals and confirms that admission criteria are met. In collaboration with an Advanced Practice Provider, the RN provides general nursing care within the scope defined by the Texas Board of Nursing and works closely with Case Management, Medical Respite, and Post-Acute Care teams. The role includes assessing discharge needs, coordinating medications and appointments, supporting home visits and client intake, providing direct nursing care and education in clients’ homes, and coordinating with healthcare and community providers. The RN also delegates appropriate tasks, supports quality assurance and infection control, and participates in continuous quality improvement while ensuring compliance with applicable standards, policies, and procedures.

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 background managing populations with complex medical needs.
Unrestricted Registered Nurse license in Texas or a compact-state license.
Basic Life Support 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 triaging and ensuring 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 necessary for quality care.
Proven written and oral communication skills.
Ability to work positively and cooperatively with employees, patients, family members, and personnel from outside agencies and organizations.
Familiarity with healthcare tools, technology, and systems, including electronic health records, 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, coordinate medications and appointments, document care, report information to appropriate personnel, and collaborate with Advanced Practice Providers, primary care providers, specialists, and community providers.
Review medications against lists provided by the discharging provider or facility.
Work with hospitals, skilled nursing facilities, community clinics, and other programs to review referrals against inclusion criteria, including traveling for an in-person assessment 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 to clients in their homes in accordance with established policies and procedures.
Complete daily and weekly quality assurance checklists, including appropriate delegation of tasks to staff (McKesson, CLIA, etc.).
Assist with oversight of infection control standards.
Participate in continuous quality improvement projects to improve service quality for patients and clients, families, and the healthcare system.
Support organizational initiatives that promote and maintain a positive workplace culture.
Triage incoming Care at Home referrals and ensure admission decisions align with program criteria.
Ensure client care tasks, administrative processes, and related duties comply with regulatory and accreditation standards and Central Health procedures and policies.