Job Description

Provides, teaches, and demonstrates professional nursing activities in accordance with policies and procedures of the agency, and as defined by the Nurse Practice Act of the State of Maryland, District of Columbia or Virginia.
Education

• Graduation from a diploma Required
• Associate's degree or Bachelor's degree program in Nursing Required
• BSN Preferred
Experience
• 3-4 years RN experience (ICU, CCU, Med-Surg, Oncology, Gerontology) within last 5 years Required
• 1-2 years Home health nursing experience Preferred
Licenses and Certifications
• Valid RN license in the District of Columbia, Maryland or Virginia, or any combination as required based on work location(s) Required and
• CPR certification Required
Knowledge, Skills, and Abilities
• IV therapy skills.
• Demonstrated comprehensive knowledge of and technical skills in home care case management and OASIS documentation.
• Strong organizational skills.
• Excellent verbal and written communication skills.
• Basic computer skills preferred.
• Smart Phone experience.
• Contributes to the achievement of established goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Completes annual Code of Conduct, Compliance, and other mandatory training. Complies with governmental and accreditation regulations.
• Analyzes and documents patients' and family's responses to interventions. Evaluates measurable progress toward goals and revise plan of care. Identifies and modifies underlying factors that impede progress toward goals. Makes recommendations for update in plan of care, using knowledge of interventions and resources.
• Collaborates with the patient's physician and staff in planning and evaluating patient care. Provides timely, pertinent written and verbal information to physicians and insurance case managers. Establishes visit schedule and informs patient/family and team supervisor. Uses a wide variety of community and agency resources as needed to meet patient needs. Independently manages activities for caseload mix of patients as experts in designated specialty. Independently organizes patient assignments for completion of tasks within acceptable time frames. Demonstrates basic leadership skills as a case manager and with other responsibilities as required. Maintains necessary clinical records, collects data and prepares reports on activities. Submits completed admission records within 48 hours. Submits daily records within 24 hours. Recertification completed prior to recert date. Maintains caseload mix and productivity for acuity level of patients.
• Delegates cases to LPN's.
• Independently develops and documents an individualized plan of care and includes patient and family in the development and revision of plan and goal setting. Care plan includes specific care interventions with expected measurable patient outcomes. Establishes and documents teaching plan for patients/families.
• Independently identifies comprehensive learning needs of designated patients. Independently develops teaching plans that specify time frames. Bases teaching and counseling plan on patient's level of knowledge, diagnosis, prescribed treatment, and available resources. Utilizes demonstration, verbal and written instruction in order to carry out care plan. Independently evaluates the effectiveness of the teaching plan in meeting patient/family goals. Revises as needed.
• Independently implements and documents plan of care for patients with complex problems or specialty needs to facilitate continuity of care. Documented interventions are related to plan of care. Interventions reflect the standard of care for patient condition/diagnosis. Interventions include utilizing agency and community resources for patients with special needs. Uses advanced nursing judgment to implement the therapeutic regime. Interventions reflect knowledge of standard and complex home care supplies/equipment used in inpatient care.
• Is responsive to and communicates respectfully with patients/families, peers, and other health team members. Initiates and participates in regularly scheduled case conferences; includes all disciplines. Includes patient and family in mutual goal setting and care plan revision.
• Maintains effective working relationships with other departments and participates in multidisciplinary quality and service improvement teams. Participates in meetings and on committees and represents the department and agency in community outreach efforts. Enhances growth and development and enriches personal knowledge and skill through participation in educational programs and affiliations.
• Performs comprehensive assessment related to an episode of patient illness, including pertinent history. Identifies COC and discharge planning needs on admission and need for other disciplines. Identifies and prioritizes problems based on assessment. Interprets abnormal clinical data to anticipate problems associated with changing patient status.
• Performs other duties as assigned.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees, and represents the department and hospital/facility in community outreach efforts as appropriate.
• Serves as an educator in the discipline, providing feedback and suggestions to improve workflow, best practices, and standard procedures. Collaborates with the Education and Operations team to develop an individualized clinical orientation program for new staff. Updates the program as needed.
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