Under the supervision of the Director of Case Management, the Care at Home Registered Nurse is an integral part of a collaborative, multidisciplinary team that will support the clients in the Care at Home Program. The Care at Home Program serves as a temporary bridge in providing healthcare services to individuals who are discharging from acute care facilities such as the hospital or Skilled Nursing Facilities. The main duties of the Care at Home RN will include the review all incoming referrals for appropriate placement to the program and ensure criteria for admission are met. In collaboration with the Advanced Practice Provider, provide general nursing care as needed as defined by the Texas Board of Nursing. The Care at Home Registered Nurse will be an integral part of the Transitions of Care team and will interact closely with Case Management, Medical Respite and Post - Acute Care teams.

Essential Functions:

• Completing accurate assessment of discharging needs, coordinating medication and appointments and documentation, reporting to appropriate personnel as indicated and working collaboratively with Advanced Practice Providers, primary care providers, specialists, and community providers.
• Medication review against list from discharging provider and/or facility.
• Work closely and collaboratively with local hospitals, skilled nursing facilities, community clinics and other programs to review incoming referrals according to inclusion criteria. This will include traveling to do an in person assessment if needed.
• Accompany Advanced Practice Provider for home visits and complete intake assessment in Electronic Health Record.
• Delegate appropriate tasks to Medical Assistant and Community Health Worker.
• Provide direct nursing care and education to clients in their homes and ensure all needs of the patient are met, in coonformance with established policies and procedures.
• Complete daily/ weekly quality assurance checklists to include delegation of trasks as appropriate to staff (McKesson, CLIA, etc.)
• Assist with oversight of infection control standards.
• Participate in continuous quality improvement projects in order to better serve the patient-client, family and healthcare system to improve the quality of service provided.
• Support organizational initiatives to promote and maintain a strong positive workplace culture.
• Triage all incoming referral for Care at Home Program and ensure admittance to program as clearly defined in program criteria.
• Ensure all tasks provided and associated with client care, patient administrative processes and related duties comply with all regulatory and accreditation standards, and Central Health Standard Operating Procedures, Policies and Procedures.

Knowledge, Skills, and Abilities:

• Demonstrates the ability to work with people from diverse socio-economic backgrounds.
• Sound critical thinking and decision-making skills.
• Skill in triaging and ensuring appropriate level of care for a patient in an accurate and efficient manner.
• Effective interpersonal skills and the ability to work with an interdisciplinary care team.
• Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures that are necessary for providing quality care.
• Proven written and oral communication skills.
• Able to relate positively, favorably and cooperatively with others, including employees, patients, family members, and personnel of outside agencies and organizations.
• Demonstrated familiarity with tools, technology, and systems typically found within most health care environments, (i.e. EHR, personal computer skills, including Microsoft Office)

Minimum Requirements:

Education :

Associate's Degree - Graduate from an Accredited School of Nursing 

Work Experience:

Three (3) years Clinical Experience in ambulatory care setting, hospital setting, home health or community agency.

Three (3) years Background in managing populations with complex medical needs.

Preferred Requirements:

Education:

Bachelor's Degree - Bachelor of Science Degree in Nursing (BSN) 

Work Experience:

Two (2) years Simple Wound Care 

One (1) year Experience with EPIC

Licenses and Certifications Requirements:

RN - Registered Nurse - State Licensure and/or Compact State Licensure: Unrestricted Registered Nurse License in the State of Texas 

Basic Life Support (BLS) - obtained through approved American Heart Association or Red Cross