RN - Home Health

Registered Nurse

This role requires the Registered Nurse to perform initial in-home pre-evaluations of patients. The evaluations will include assessing health status, strengths, care needs, and preferences. These assessments will guide the development of individualized long-term care service plans. The nurse will review medical documentation and health referral forms as relevant to each case. Evaluation data must be entered into an electronic form and transmitted as required.

Any concerns, conflicting information, or other issues that arise during the evaluation must be documented. Emphasis will be placed on continuity of care to reduce fragmentation, duplication, and gaps in treatment plans. The nurse will discuss health care options, supports needed, service vendor options, and waiver options with consumers. Communication will be initiated between the call center and eligible consumers for enrollment into the managed care health plan.

Collaboration with interdisciplinary care team members is essential to improve care coordination and facilitate service delivery. Quality review data and required documentation will be collected to support outcome measurements and recorded case notes into the CRM. Opportunities for health promotion and illness prevention should be identified during the assessment process. The nurse will maintain a comprehensive knowledge of community resources and payor requirements for the target population.

The nurse will meet all standards outlined for the position according to annual performance criteria. Additional duties may be assigned by the Regional Nurse Manager or project management as necessary.