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Community Health Nurse

1 month ago

Bronx, New York, United States Mitchell Martin Full time
Job Title: Community Health Nurse

We are seeking a highly skilled and compassionate Community Health Nurse to join our team at Mitchell Martin. As a Community Health Nurse, you will play a vital role in providing skilled care and routine clinical nursing assessment visits to our members and their families.

Job Summary:

The Community Health Nurse will work under the direction of a Care Manager to provide nursing visits in the member's home, PACE center, hospitals, nursing homes, and other alternate settings as deemed necessary for care coordination. The successful candidate will be a core member of our interdisciplinary team, working closely with other healthcare professionals to develop and implement comprehensive care plans that meet the unique needs of our members.

Responsibilities:
  • Carry out the organization's mission, philosophy, goals, and objectives within guidelines of policy and position function.
  • Interpret and implement the organization's philosophy to staff and members of the community.
  • Assume responsibility for assignments given, seek supervision appropriately, and be accountable for actions by performing within the limits of education and experience.
  • Know and conform to the law governing the practice of professional nursing and provide professional nursing care using all elements of the nursing process.
  • Assess and evaluate the health care needs of patients and families with consideration regarding physiological, psychological, social, and environmental factors.
  • Identify complete, accurate, and logical Uniform Assessment System (UAS) for NY and appropriate sequencing of diagnoses in collaboration with the PCP to maintain compliance with state and federal regulations.
  • Maintain constant and ongoing communication with the assigned Care Manager in regards to the participants' health status, clarify questions regarding notes entered in the EMR, and discuss any and all other relevant information that needs to be used by the Care Manager while representing the CHN in care planning and IDT meetings.
  • Collaborate with all members of the IDT in developing a comprehensive care plan based on member-specific needs, physician orders, UAS-NY CAPS, other IDT assessments, members' specific parameters, and identified goals that are respectful of member, family, community, and organizational resources.
  • Implement the nursing care plan and revise it whenever necessary by regularly assessing, observing, and evaluating the patient's condition, needs, and response to care and making appropriate nursing judgments and decisions for care plan revision.
  • Initiate and apply appropriate preventative, therapeutic, and rehabilitative nursing procedures and techniques.
  • Administer medications and treatments as prescribed by the PCP.
  • Ability to independently perform skilled nursing procedures and techniques based on the changing nursing needs that the member requires.
  • Teach the patient and family/caregivers self-techniques whenever appropriate and provide instruction regarding medication, diet, safety, and treatment modalities in accordance with the plan of care.
  • Recognize and utilize additional opportunities for health counseling/education with patients, families, and other caregivers and provide them with information that will facilitate decisions regarding the promotion, maintenance, and restoration of health.
  • Delegate responsibility appropriately and supervise ancillary personnel in a manner that will assure quality care and compliance with the care plan.
  • Evaluate for and promote a safe environment for the patient and comply with National Patient Safety Goals.
  • Complete, maintain, and submit all required documentation that is timely (in compliance with organizational policy), accurate, and relevant.
  • Meet all requirements for UAS-NY assessor function: timely completion within regulatory standards, follow-up assessments, and significant change assessments as needed.
  • Reviews and confirms eligibility of member in the PACE program based on Nursing Facility Level of Care (NFLOC) score obtained from the UAS-NY assessment.
  • Confirms eligibility of members with the members of the IDT.
  • Performs care coordination as part of their nursing visits to PACE members across all settings of care.
  • Collaborative care coordination to include internal (e.g., other IDT members) and/or external health care professional (e.g., MD specialists, SNF staff, hospital staff) in a manner that assures care plan coordination as well as continuity of care.
  • Performs periodic Nutrition Risk Screen (NRS) and coordinates member referral to a Dietician when needed.
  • Assumes responsibility for personal growth and development; maintains and upgrades professional knowledge and practice skills through attendance/participation in continuing and in-service education programs.
  • Meets organizational productivity guidelines.
  • As requested by supervision, participates in and assists with staff and student orientation and development; participates in internal and external committee activities; and represents the organization in the community.
  • Participates in performance improvement activities, as required.
  • Participates in evaluating overall position performance, goal setting, and achievement, and performance improvement plan.
Qualifications:
  • Degree from an NLN accredited school of nursing required, BSN preferred.
  • A current New York State License to practice as a Registered Nurse.
Experience:
  • Minimum of one (1) year current skills clinical nursing experience in a certified home health agency (CHHA), acute care, medical surgical, and/or critical care experience required.
  • Current is defined as having this experience within one (1) year of date of hire or transfer.
  • Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.
  • Possess and maintain good physical stamina and mental health, including satisfactory health clearance as required by NYS regulations and/or organizational policy.
  • Current Driver's License, required insurance, and car available for work as required.
  • Some Homecare and Field Experience required.
Knowledge, Skills, and Abilities:
  • Computer/laptop proficiency required.
  • Good organizational, observation, communication, and judgment skills.
  • Is self-directed with ability to work with supervision.
  • Is flexible and cooperative in fulfilling role obligations.
Additional Requirements:
  • Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.
  • Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.
  • Computer/laptop proficiency required.
  • Good organizational, observation, communication, and judgment skills.
  • Is self-directed with ability to work with supervision.
  • Is flexible and cooperative in fulfilling role obligations.