RN Transitional Care Coordinator (Home Health & Hospice)

RN Transitional Care Coordinator (Home Health & Hospice) Midland, TX Description About Us: At Interim Healthcare, we believe Hospice & Home Health care is more than a service—it’s a calling. Every day, our team brings comfort, dignity, and peace of mind to patients and families facing life’s most delicate moments. With compassion at our core, we create a workplace where kindness leads, voices are heard, and every role carries purpose. If you’re looking to make a difference in the lives of others while being part of a team that feels like family, we’d love to welcome you. Job Summary Primary functions are to administer skilled nursing care for clients of all ages in their place of residence, coordinate care with a multi-disciplinary team, patient/family and referring agency; and assume the responsibility for coordination of care. Works independently without on‑site supervision. Essential Functions Demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in the application of the nursing process. Demonstrates knowledge and competency in performing baseline nursing skills as outlined in Agency policy and clinical policy; maintains clinical competencies according to home‑care standards; complies with state practice act. Administers all medications and treatments according to Agency policy, accepted standards of care and home healthcare guidelines. Communicates effectively with other nurses, patients, families, and physicians; documents patient status, patient needs/problems, nursing interventions/patient response, safety interventions and education/teaching. Performs accurate assessments, develops and implements a written Plan of Care with the patient, following physician’s orders and according to Agency guideline; performs and documents nursing interventions including patient education according to the Plan of Care and adapts these actions as patient needs change. Documents patient status in an accurate, timely and concise manner as required by Agency policy; addresses patient needs and problems, nursing interventions and patient response, safety interventions and education and teaching. Demonstrates organization and leadership abilities by effective use of time and personnel through supervision and teaching; effectively establishes priorities and delegates responsibilities appropriately when supervising the LVN/LPN and home health aide. Maintains a committed and cooperative attitude with staffing, promoting teamwork and harmony by readily assisting other staff and patients; participates in case conferences/team meetings. Makes visits as scheduled and participates in on‑call rotation as required. Additional Responsibilities Performs related duties as assigned or requested. Possesses adequate knowledge of Medicare/Medicaid and insurance standards to ensure reimbursement for all services rendered. Conforms to all applicable Agency policies and procedures. Participates actively in continuing education and in‑services. Maintains confidentiality of patient information and business trade practices. Assumes accountability for reporting incidents and complaints according to Agency policy. Knowledge / Skills / Abilities Advanced written and verbal communication skills. Organizational skills. Ability to supervise in accordance with Agency’s policies and applicable laws. Advanced math skills related to patient care. Ability to respond to common inquiries or complaints, regulatory agencies or members of the business community. Cooperative attitude. Information Management Treats all information and data within the scope of the position with appropriate confidentiality and security. Cooperates fully in all risk management activities and investigations. Keeps abreast of changes in health care law. Maintains agency/program compliance with local, state, and federal laws as well as state accreditation standards. Minimum Position Qualifications Education: Graduate of an accredited school of nursing. Experience: One year of experience in nursing. License / Certification: Current State RN license; current CPR; current driver’s license and proof of auto liability. Environmental Conditions Works in patient’s home in various conditions, possible exposure to blood and body fluids and infectious diseases. Ability to work flexible schedule, ability to travel locally, some exposure to unpleasant weather. Moderate noise level; tasks may involve moderate stress and emotional demands. Physical Requirements Prolonged standing and walking required. Ability to move up to 50 lbs. and move patients. Requires working under some stressful conditions to meet deadlines, to identify patient needs, to make quick decisions and resource acquisition; meet patient/family psychosocial needs. Requires hand‑eye coordination and manual dexterity. Ability to utilize durable medical equipment in the home. The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities. #J-18808-Ljbffr