Registered Nurse - Home Health (Flexi)

Summary The Home & Supportive Care Registered Nurse (RN) provides excellent, clinically competent care and effectively interacts with patients/families and healthcare team members, while maintaining standards of professional nursing. As a member of the healthcare team, the RN is responsible for making decisions and performing services that are in the best interest of the patient, while positively contributing to the patient's experience. The Home & Supportive RN provides education and performs assessment, planning, implementation, monitoring, and evaluation of nursing care for acutely ill, chronically ill, terminally ill, and well patients with multiple managed conditions, to ensure cost effective and efficient utilization of health services.

Essential Duties and Responsibilities

• Provide clinical care management services to identified eligible patients; coordinating care and care transitions to obtain desired health outcomes.
  • Foster collaboration, shared decision-making, and partnership among clinical and non-clinical care team members.
  • Perform patient/family/caregiver outreach according to established protocols.
  • Ensure patient eligibility for assigned Home & Supportive Care services and assist with discharge planning and coordination of admissions upon discharge to home, facility, or other residence.
• Identify, enroll, and manage patients in programs for Supportive Care Advanced Illness Management and Transitions of Care.
  • Co-manage a diverse population living with one or multiple chronic conditions.
  • Collaborate with patient, provider, and care team to develop and implement a plan of care to ensure medically appropriate, cost-effective care.
  • Identify, execute, and track needed referrals to care and community resources.
  • Provide resource management to improve care, patient experience, and collaborate with Home & Supportive Care providers to effectively implement a patient-centered care plan.
• Provide comprehensive care for patients with chronic conditions through Connected Care @ Home remote patient monitoring and make impactful judgment calls using clinical data tools.
  • Provide ongoing remote clinical monitoring to patients in partnership with their providers, making informed escalation and triage decisions.
  • Collaborate with care team to provide remote clinical monitoring of physiological data based on outlined pathways and ensure seamless care coordination according to each patient’s individual care plan.
  • Engage with patients through text and voice/video calls, remotely reviewing patient/client data and health information.
• Showcase strong time management skills, enabling the ability to make impactful judgment calls on patient care while balancing all other responsibilities and time engagements.
• All Home & Supportive Care Registered Nurses may function as a nursing member of the Home & Supportive Care team, performing patient care encounters as assigned.

Supervisory Responsibilities Reports to: Nurse Manager and Clinical Coordinator Supervises: Licensed Practical Nurses (LPN) and Unlicensed Assistive Personnel (UAP) Responsibilities: May delegate/assign duties to other members of the healthcare team Education and Experience Minimum Required Education: Associates Degree in Nursing Preferred Education: Bachelor of Science in Nursing Experience: 1 year inpatient, outpatient, or home-based nursing experience is preferred.

Certificates, Licenses, Registrations Applicants must have current licensure or be eligible for licensure as a Registered Nurse in the State of Virginia or compact state. BLS within 90 days.