Field Registered Nurse Homecare Dimensions

Opportunities at Well Med, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring.

Connecting. Growing together.

The Registered Nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

• Patient Care
  • Completes an initial assessment of patient and family to determine home care needs Provides a complete physical assessment and history of current and previous illnesses
  • Regularly re-evaluate patient nursing needs
  • Uses health assessment data to determine nursing diagnosis
  • Initiates and develops a Plan of Care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventative, and rehabilitative nursing care actions Includes the patient and the family in the planning process Makes necessary revisions as patient status and needs change
  • Plans and implements patient health teaching and health counseling regarding the disease process(es), self-care techniques and prevention Counsels and involves the patient and patients' family in accomplishing healthcare goals, meeting nursing and related needs while promoting patient/family independence
  • Re-evaluates patient nursing care needs to include continuous assessment using the OASIS Data Set at appropriate time intervals during the episode
  • Assesses the patient's condition during every home health care visit; ensures assessments are communicated to the Clinical Team Manager (CTM) on a daily basis; nursing interventions are implemented to meet patient needs and changing conditions
  • Initiates appropriate preventive and rehabilitative nursing procedures Administers medications and treatments as prescribed by the physician
  • Identifies patient discharge planning needs as part of the Plan of Care development and implements prior to discharge of the patient
  • Assumes responsibility to coordinate all patient care
  • Recognizes and reports life threatening situations and responds appropriately
  • Provides information regarding Home Medical Equipment (HME) and supply needs to the CTM, in a timely manner Utilizes equipment and supplies effectively and efficiently
  • Performs care management duties for patients as assigned including: notifying the physician of changes in the patient's condition or progress toward goals, obtaining physicians orders as needed, reassessing the patient for recertification, attending and documenting case conferences, initiating coordination of care by reporting significant findings to others on the healthcare team, and planning for notification and documenting the discharge of the patient
  • Adheres to the Agency's Standard Operating Procedures as it relates to the submission of documentation
  • Documents all communications with the patient, family, physician, CTM, pharmacy, and other disciplines, as indicated on communication notes
  • Prepares a written plan for the certified Home Health Aide to follow, if applicable
  • Established a trusting relationship with patients, caregivers, co-workers, clinic staff members, and physicians
  • Demonstrates knowledge and observance of Patient Rights and Notice of Privacy Practices
  • Follows all infection control standard precautions and safety guidelines/standards as per agency policy
  • Participates in educational programs and all required in-service training programs to maintain comprehensive healthcare knowledge base, as assigned by supervisor
  • Complies with all Homecare Dimensions, Inc agency's policies and procedures Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies Participates in the agency's endeavors for accreditation, licensing, and professional recognition according to state, federal, and/or CHAP requirements Participates in the Performance Improvement Program activities of the agency and periodic review of clinical records, as assigned
• Communication
  • Prepares clinical notes and updates the primary physician when necessary and at least every sixty (60) days
  • Communicates with the physician regarding patient needs and reports any changes in patient condition; obtains/receives physician orders as required
  • Communicates with community health related personnel to coordinate the Plan of Care
  • Coordinates services and schedules with the Clinical Team Manager (CTM) and Clinical Team Coordinator (CTC/Scheduler) to include recommendations for additional home health care services for patients within twenty-four (24) hours of the Start of Care (SOC)
• Additional Duties
  • Participates in on-call duties within the…