Home Health RN On-Call Nurse

Home Health RN On-Call Nurse

Bienvivir All-Inclusive Senior Health ("Bienvivir") is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly ("PACE").

PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.

Bienvivir is currently accepting applications for the following position:

HOME HEALTH RN ON-CALL NURSE

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 determine 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.

CORE RESPONSIBILITIES:

• Communication
• 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.
• Manages 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 arranging 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.
• Maintains communication regarding participant's care with the Provider, HH Nursing Supervisor, and family, as appropriate.
• Provides a comprehensive end-of-shift email report to support continuity of care, detailing all interventions and resolutions rendered.
• Direct Participant Care
• Performs Skilled Nursing visits in participants' private residences, assisted living facilities, and other approved locations for Bienvivir participants.
• Provides nursing interventions according to the participants plan of care
• Administers medications and treatments per provider orders.
• Facilitates transitions of care and supports continuity across settings, including hospital, skilled nursing facility, and home transitions.
• Observes participants for changes in condition and promptly reports findings to the provider and/or designee.
• Nursing Assessments
• Completes 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.
• Completes reassessments promptly at the request of the participant, designated representative or on-call MD/NP, with urgency…