Home Health RN)

Augusta Health Careers•Fishersville, VA

About The Position

The Registered Nurse Care Manager manages and coordinates hospice patients’ plans of care in their place of residence, coordinating with the interdisciplinary team, patients, families, referring agencies or facilities, and caregivers. The RN administers nursing care in accordance with the medical plan and nursing standards, directs patient and family education, and guides other personnel while maintaining professional nursing standards. The role requires assessing patient information and developing care plans that address age-specific needs and providing care consistent with departmental policies and procedures. The position supports Augusta Health’s mission, departmental goals, and patient-centered service and outcome priorities. The Care Manager completes initial and ongoing assessments, establishes individualized plans of care, determines hospice eligibility and levels of care, monitors patient and family responses, and communicates changes and outcomes to providers and the interdisciplinary team. The role includes medication reconciliation and safe medication administration, clinical documentation, patient and family education, end-of-life comfort and outcome support, coordination of referrals and services, and appropriate use of supplies and services. The RN provides clinical direction and supervision to Hospice Aides and LPNs, performs supervisory visits, mentors and orients staff as assigned, and contributes to quality improvement, staff development, and organizational committees as requested. The role also requires safe clinical practice, infection-control and patient-safety compliance, proficiency in IV starts and phlebotomy, effective communication, and use of computer applications for documentation and information retrieval. A flexible schedule is required. A driver’s license is required; driving an Augusta Health vehicle additionally requires being at least 21 years old and receiving Motor Vehicle Record approval from Risk Management.

Requirements

Nursing diploma and/or Associate Degree in Nursing.
Current and valid Registered Nurse license in Virginia or a state participating in a Compact Agreement with Virginia.
CPR-Basic Life Support Healthcare Provider (BLS-HCP) certification.
At least one year of recent RN experience.
Valid driver’s license.
Eligibility to work in the United States and ability to meet Virginia state employment requirements.
Ability to work a flexible schedule.
Knowledge and skills in IV therapy, wound care, and general medical/surgical assessment.
Clinical competence in hospice care and completion of annual education requirements and department competencies.
Good leadership and communication skills.
Job-related computer competence for patient documentation and information retrieval; ability to submit documentation timely.
Practice within the scope of the Nurse Practice Act and familiarity with current Standards of Nursing Practice.
Familiarity with CMS hospice regulations and ACHC standards applicable to daily work.

Nice To Haves

BSN or MSN.
CHPN certification.
Hospice experience.
Prior experience in a hospital, healthcare system, or related service-oriented environment.
Familiarity with Augusta Health systems, workflows, or organizational culture.

Responsibilities

Manage and coordinate hospice patients’ plans of care in their residences with the interdisciplinary team, patients, families, referring agencies or facilities, and caregivers.
Administer nursing care according to medical plans, nursing standards, department policies, and established practice guidelines.
Complete medication safety checks, demonstrate knowledge of medications and high-risk medications, perform calculations for mixtures or solutions, and reconcile medications and changes with providers.
Evaluate patient outcomes; implement, document, and revise plans of care to support quality and continuity.
Complete initial and ongoing comprehensive assessments appropriate to the patient’s age, care needs, knowledge, and psychosocial, emotional, physical, functional, environmental, and spiritual needs.
Apply hospice admission and recertification criteria to establish eligibility and appropriate levels of care; reassess patients as their conditions warrant.
Communicate patient needs, changes, interventions, and outcomes to providers, the interdisciplinary team, and other nurses as needed.
Educate patients and families about disease processes, self-care, end-of-life care, nutrition, and dietary needs; evaluate and document learning and feedback.
Determine the scope and frequency of services based on acuity and patient and family needs, and assess caregiver ability to meet immediate needs.
Prepare timely clinical and progress notes demonstrating progress toward established goals and documenting interventions, patient responses, and follow-through.
Make appropriate referrals and document follow-up in the medical record; coordinate care through interdisciplinary services as needed.
Support patient comfort and outcomes at end of life and use services and supplies responsibly.
Provide clinical direction to Hospice Aides and LPNs, complete required supervisory visits, and supervise supportive nursing staff to ensure quality and continuity of care.
Serve as a team resource and mentor; provide mentoring and orientation to nurses, students, and aides as assigned.
Implement clinical and technical care, anticipate complications, and use preventive measures; demonstrate skills in pain management, systems assessment, and patient satisfaction.
Demonstrate proficiency in IV starts and phlebotomy and follow applicable policies and procedures.
Document at least 75% of care at the point of care and use required computer applications for documentation and information retrieval.
Maintain patient safety, confidentiality, assigned equipment, and a safe care environment; report equipment damage or problems and complete quality controls as required.
Follow infection-control, PPE, isolation, hand hygiene, sharps, medication, infectious-waste, specimen-labeling, fall-prevention, patient-identification, handoff, and emergency-preparedness procedures.
Use SBAR for provider communication and patient handoffs; respond calmly and promptly in emergency situations.
Practice safe driving and follow safe body mechanics and procedures when caring for patients who may display aggressive or violent behavior.
Maintain clinical competency, complete annual education and department competencies, attend required in-services and at least 50% of staff meetings, and pursue personal learning and development.
Participate in quality-improvement processes and staff-satisfaction projects; assist with projects as requested and maintain knowledge of department QAPI projects and ACHC standards.
Follow Augusta Health service standards and hospice philosophy, cooperate with interdisciplinary colleagues, support cost containment, and maintain dependable attendance.
Serve on organizational committees when requested by the Clinical Manager.

Benefits

Medical, dental, and vision insurance coverage.
Retirement savings plans and financial wellness support programs.
Paid time off.
Flexible scheduling.
Career development programs, including clinical ladders, shared governance, and advancement opportunities.
Personalized onboarding with dedicated preceptors and ongoing educational support.
Tuition reimbursement.
Onsite childcare.
Free onsite parking.
24/7 armed security.
Health Fitness Reimbursement Program.
Onsite credit union and pharmacy.
Competitive pay with shift and weekend differentials.
Employee discounts at the cafeteria, gift shop, pharmacy, and local entertainment venues.