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The Home Health Registered Nurse (RN) 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. This role involves collecting data from patient assessments, telephonic contacts, and EMR information, analyzing this data to identify issues and resources, and determining effective resolutions. The RN identifies patients at high risk for re-hospitalization, falls, or high utilization of resources, implementing interventions and case conferencing to ensure appropriate care and mitigate risks for high-quality outcomes. They prioritize multi-issue situations based on criticality, patient/staff safety, and impact on services. The position also involves identifying barriers to resolution (e.g., language, literacy, psychological) and utilizing appropriate resources or leadership for timely and effective follow-up. A key responsibility is developing and overseeing a plan of care that is effectively communicated and supports quality patient outcomes and satisfaction. The RN implements the plan, directs care coordination within a multidisciplinary clinical team, and supervises LPNs and/or HHAs involved in patient care. They perform ordered treatments, therapies, and procedures in accordance with relevant regulations and policies, and evaluate progress towards patient-centered goals.
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Job Type
Full-time
Career Level
Mid Level

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