Nurse Care Coordinator
1 month ago
The Registered Nurse in Home Health provides and directs provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. The Registered Nurse coordinates total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. All done within a Point of Care setting.
Responsibilities
1. Clinical Competence Initiates, develops, implements, and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care. Directly and/or indirectly supervises care provided by the home health aides and licensed practical vocational nurses, provides instruction as appropriate, and assigns tasks according to State and federal regulations. Also provides required supervisory visits.
2. Documentation and Care Delivery Provides high quality clinical services within the scope of practice and within infection control standards, in accordance with the plan of care, and in coordination with other members of the health care team. Accurately and timely completes the comprehensive assessments (OASIS) including medication reconciliation. Accurately and thoroughly documents patient visits per policy, and payer requirements and syncs timely per LHC policy.
3. Quality Makes the initial and/or comprehensive nursing evaluation visit, ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source, accurately determines primary focus of care, develops the plan of care within State specific guidelines with the physician, and submits accurate documentation. Communicates relevant information timely and effectively with appropriate agency staff including but not limited to: any patient care issues or needs, visit assignments, dates of scheduled visits, and schedule changes to scheduler, orders and OASIS data sets, coding requests, schedule home visits, to coordinate care with other clinicians, Communicates timely and effectively with physicians, patients, and family members to ensure quality care and service excellence.
4. Professionalism (on time, completes training, compliant) Comes to work each day with a positive attitude, willing to help the patient and agency in any way they can. Is open to learning new skills. Is punctual for all meetings and actively participates in all meetings including case conferences. This includes having a camera on for video meetings.
5. Teamwork (on call, productivity) Takes direction from Clinical Director and Executive Director professionally and completes tasks assigned timely, including required learning. This includes all other duties as assigned. Assists in the orientation of new agency personnel and serves as a preceptor to other staff and students. Actively participates in the survey/survey readiness activities, performance improvement plan including but not limited to: constantly works to reduce unnecessary patient hospitalizations, improve patient safety, and implements processes and best practices to ensure positive patient outcomes. Participates in on-call rotation and weekend rotation as needed to meet patient needs. Adheres to and participates in the agency's utilization management model.
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