Responsible to the Administrator/Patient Care Coordinator to provide nursing care and case management to patients and families. Implements nursing interventions and coordinates the patient/family interdisciplinary plan of care. Supervises personnel to deliver care and coordinates care delivery.
Essential Job Functions
Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar or is a logical assignment of the position.
Manages a patient and family caseload which includes assessing, planning implementation, evaluating and documenting the care provided.
Plans, coordinates and delivers nursing care to patients and families.
Supervises and documents home health aide/licensed practical nurse plans of care and documents supervisory visits.
Participates in on-call coverage.
Submits paperwork in a timely manner and updates and maintains patient medical records.
Participates in regularly scheduled interdisciplinary team meetings to coordinate the care of the patient and family, exchange information and problem solve, and receive staff support and education.
Applies the policies and procedures of the agency and the rules and regulations of Federal and State regulatory agencies and other certifying agencies in providing care.
Coordinates and develops patient/family plan of care and ensures the care plan is current, up to date and reviewed at every team meeting.
Assesses and evaluates patients� level of care, needs and requirements.
Participates in agency quality improvement programs.
Ensure growth and profitability of the company through the responsible use of company resources and educating the community to our services.
Assess the patient�s response to the Plan of Care and recommends changes as needed.
Meets or exceeds established productivity standards.
Provides education to the patient/family regarding the disease process, self care techniques, prevention strategies, rehab nursing procedures and community resources of discharge planning.
Initial and ongoing comprehensive assessment of patient�s needs including Outcome and Assessment Set (OASIS) at appropriate time sets.
Evaluating Outcomes of Care.
Provide counseling to patient/family regarding disease process, end of life and ethical issues.
Willingly accepts direction from Administrator.
Participates in community programs and committees, as requested.
Supervises LPN/LVNs, home health aides and paraprofessionals providing services to the patient according to regulatory guidelines.
Monitors that documentation from LPN/LVN, home health aides are complete,
Participates in in-service programs
Assesses the ability of the caregiver to meet the patient�s needs at admission and throughout care.
Ensures that employees are adequately oriented and trained to assignment; assists and encourages employees in developing their skills and self confidence.
Initiates appropriate preventative and rehabilitative nursing procedures. Prepares clinical progress notes that demonstrate progress towards goals. Coordinates patient/family services and prioritization of needs with members of the interdisciplinary team, Uses case management approach and refers to other services as needed. Determines scope and frequency of services needed based on acuity and patient/family need.
Adheres to established personnel policies.
Accepts other assignments deemed appropriate.
Ensures that care is provided with respect for patient rights.
Ensures protected health information is kept confidential.
Reports complaints made by patients or families to the appropriate persons.
Adheres to established personnel policies.
Reports allegations of patient abuse, neglect and/or misappropriation of patient property.
Safety and Sanitation
Follows standard precautions and infection control procedures.
Reports all accidents and incidents observed.
Identifies and responds appropriately to emergency situations.
Assures safety needs of the patients are addressed and met.
Educates staff in clinical aspects, as needed.
Attends in-services and meetings as required.
Participates in orientation of new staff.
Delivery of Care Responsibilities
Participates in in-service training as requested by the office.
Reviews and evaluates treatment plans for all patients served.
Communicates appropriate clinical information to the interdisciplinary team regarding care issues and patient/family needs.
Provides documentation of patient visits on the clinical record as appropriate.
In conjunction with the physician and interdisciplinary team, assures appropriate treatment is given to patient and families.
Addresses patient care needs with families and significant others as appropriate.
Collaborates with all service providers furnishing contract services to the patient.
Participates in developing and updating policies and procedures as requested.
Maintains confidentiality of necessary information.
Thinks and acts calmly and logically to meet unusual occurrences of the job.
Maintains proper documentation for billing.
Manages time efficiently and effectively.
Interfaces with patients, families, and staff to ensure customer satisfaction.
Develops a comprehensive discharge plan based on the interdisciplinary team assessment.
In conjunction with the physician, evaluates need for appropriate diagnostic studies and/or tests.
Communicates effectively with patients, families and other health care providers.
Maintains clinical competency by assuming responsibility for acquiring knowledge and experience to meet learning needs.
Create positive image between co-workers.
Promote positive inter-agency communication.
Instill confidence in staff members and build self-esteem through acceptance and recognition of employees.
Provide role modeling of team work, accountability and a positive attitude.
Demonstrate and encourage appropriate problem solving methods.
Currently licensed as a Registered Nurse (RN) in the state and in good standing with the State Board in which he/she practices.
Demonstrates problem solving and decision making abilities.
Ability to manage patient care with specific knowledge and experience in bedside nursing, symptom management, crisis intervention and family intervention.
Excellent written and verbal communication skills.
Ability to develop and maintain rapport with patients and family.
Ability to work well with an interdisciplinary team.
A minimum of 6 months institutional nursing experience within the past 3 years, unless state regulations differ. The Administrator may waive this experience requirement based upon a personal interview.
Lifting 50 pounds maximum with frequent lifting and or carrying of objects weighing up to 25 pounds; walking, standing, talking, hearing, pushing, fingering, reaching, seeing, stooping, smelling, depth perception, color vision and driving.
Necessary on a daily basis; 100%
Patient�s home/living facilities.
Exposure to disagreeable conditions including odors, infection, illness and physical contact from disruptive patients.
Office staff, patients, families, physicians, Administrator, Patient Care Coordinator and community health care providers.
Must be flexible to accommodate completion of tasks, patient needs and referrals.
Must be able to execute the terms and conditions set forth in the SCL Handbook including, but not limited to:
Works in a safety-conscious manner which ensures that safe work practices are used in order not to pose a risk to self or others in the workplace. Reports any safety violations or hazards to supervisor.
Complies with company policies and procedures and local, state, and federal regulations.
Adheres to policy on Drug-Free Workplace.
Interacts in a tactful, diplomatic, and humanistic manner with residents, families, visitors, and co-workers to provide a safe, efficient, and therapeutically effective caring environment which ensures the self-respect, personal dignity, rights and physical safety of each resident and facility guest.
Maintains a dependable attendance record and adheres to standards of cleanliness, grooming, hygiene, and dress code.
Takes positive action to ensure equal opportunity in the conduct of all business activities without regard to race, color, religion, sex/gender, age, national origin, disability, citizenship, veteran status or any other legally protected category.