Home Health RN On-Call Nurse

GENERAL DESCRIPTION:

Under the supervision of the Home Health Nursing Supervisor, the Home Health (HH) Registered Nurse (RN) on‑call is responsible for providing on‑call nursing coverage during assigned shifts to ensure continuity of care for all Bienvivir participants. The RN will answer calls via telephone and provide clinical triage by responding to participants, family, on‑call MD/NP and caregiver calls, and determining the need for Skilled Nursing (SN) visits.

The RN conducts scheduled and as‑needed SN visits to complete triage assessments, manage symptoms, and address changes in participant condition. The RN provides direct nursing care with an emphasis on effective communication, symptom and disease management, participant and caregiver education, prevention and maintenance interventions, accurate documentation and regulatory compliance, in accordance with Texas Health and Human Services Commission (HHSC) requirements.

• Be available via telephone to receive and prioritize calls from BSHS telephone answering system and to follow up with participants’ medical needs and concerns.
• Monitor and retrieve voicemail messages during assigned on‑call hours. Return calls in a timely and professional manner. Coordinate with nurse triage line, providers, or emergency services as needed. Triage participant concerns based on clinical urgency; providing clinical guidance based on scope of practice.
• Manage after‑hours communication related to participant emergency room visits, hospital admissions, and discharges. Responsibilities include notifying providers and the interdisciplinary team, coordinating and reviewing discharge orders, communicating care needs to facilities or caregivers.
• Work in coordination with other after‑hours on‑call staff via phone to address participant medical needs and arrange urgent medications, DME, or services.
• Communicate effectively with participants, caregivers, and designated representatives to coordinate care and respond to clinical concerns and phone calls promptly.
• Maintain communication regarding participant’s care with the Provider, HH Nursing Supervisor, and family, as appropriate.
• Provide a comprehensive end‑of‑shift email report to support continuity of care, detailing all interventions and resolutions rendered.

• Perform Skilled Nursing visits in participants’ private residences, assisted living facilities, and other approved locations for Bienvivir participants.
• Provide nursing interventions according to the participants plan of care.
• Administer medications and treatments per provider orders.
• Facilitate transitions of care and support continuity across settings, including hospital, skilled nursing facility, and home transitions.
• Observe participants for changes in condition and promptly report findings to the provider and/or designee.

• Complete Start‑of‑Care, routine, and as‑needed nursing assessments, including evaluation of medication compliance, symptom burden, functional status, changes in condition and death assessments within 24 hours of participant encounter.
• Complete reassessments promptly at the request of the participant, designated representative or on‑call MD/NP, with urgency determined by clinical severity, during shift.
• Document all assessment findings accurately and timely in the medical record within 24 hours of participant encounter.
• Perform death assessment and pronouncement if appropriate, following organization policies and Texas Health and Safety Code.

• Implement evidence‑based interventions for participants with advanced illness and chronic disease.
• Monitor disease progression and symptom trends through ongoing assessments and telephone follow‑ups with participants and/or caregivers, adjusting care proactively as needed.
• Support chronic disease management within a comfort‑focused plan of care, prioritizing symptom relief and minimizing burdensome interventions.
• Collaborate closely with Comfort Care providers to recommend medication adjustments, alternative therapies, and supportive measures consistent with participant goals.
• Ensure all…