Registered Nurse - Hospital - Home Health Care/Hospice

Clinical Care & Patient Assessment

Conduct comprehensive in-home and telehealth nursing assessments, evaluating physical, psychosocial, and environmental factors that impact health outcomes.

Meet members in a variety of settings that may include, but not limited to houses, group homes, skilled nursing facilities, etc.

Perform vital signs monitoring, review medical history, complete medication reconciliation, and identify potential safety or adherence risks.

Provide clinical nursing interventions as appropriate, including wound care, medication administration, and patient teaching.

Identify and respond to changes in patient condition, collaborating with physicians and care teams to implement timely interventions.

Quality delivery of clinical assessment skills and practices.

Deliver palliative and supportive care focused on comfort, dignity, and quality of life, addressing pain, symptom management, and emotional well-being.

Participate in transitions of care, helping patients navigate from hospital to home or between care settings safely and effectively.

Must be comfortable having end-of-life conversations, planning, and assisting with the completion of advance directives.

Care Coordination & Case Management

Develop, implement, and revise individualized care plans that integrate medical, behavioral, and social determinants of health.

Serve as the clinical liaison between patients, families, providers, and community agencies to ensure seamless, coordinated care.

Partner with physicians, advanced practice providers, social workers, and therapists to conduct interdisciplinary case reviews and panel management.

Conduct follow-up calls, telehealth visits, and home visits to monitor progress and reinforce care plans.

Facilitate access to resources such as hospice referrals, behavioral health support, transportation, and food security services.

Provide disease-specific education to patients and caregivers on conditions such as diabetes, COPD, hypertension, heart failure, and dementia.

Educate on symptom recognition, medication safety, nutrition, exercise, and advance care planning.

Empower patients to participate actively in self-management and care decisions.

Ability to help coordinate care plans for the patient and family.

Community Outreach & Resource Navigation

Conduct home safety evaluations and recommend adaptive equipment or environmental modifications to enhance independence and reduce risk.

Engage in community outreach to connect patients with social, financial, and medical resources that support well-being.

Collaborate with outreach teams to locate and re-engage patients who are non-compliant or difficult to reach.

Participate in community events, health fairs, and patient education programs to promote awareness of available services.

Accurately document all assessments, interventions, communications, and outcomes in the Electronic Health Record (EHR) in accordance with policy and regulatory requirements.

Maintain strict adherence to HIPAA regulations, ensuring confidentiality and data integrity.

Track and report quality metrics, patient outcomes, and care coordination activities to support program improvement.

Mentor and provide guidance to LVNs, Medical Assistants, and community health staff as appropriate.

Participate in bi-weekly care team huddles, clinical rounds, and performance improvement initiatives.

Engage in continuing education and maintaining clinical competencies relevant to community-based nursing and palliative care.

Adapt to evolving technology platforms, documentation systems, and clinical protocols.

Two (2+) years of clinical nursing experience.

One (1+) year in community health, home health, ambulatory care, population health, or palliative care, or hospice care strongly preferred.

Strong understanding of chronic disease management, transitions of care, and social determinants of health.

Ability to work independently and exercise sound clinical judgment in non-traditional care environments.

Proficiency with electronic health record (EHR) systems and Microsoft Office Suite.

Knowledge of HIPAA and regulatory requirements for patient privacy and safety.

Must be able to travel up to 40% within assigned geography. (Reliable transportation, valid driver’s license, and proof of auto insurance required.

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