Large, Established, and Respected Certified Home Care Agency / CHHA / is looking for a Field RN/Coordinator of Care in Upper Brooklyn, NY
Salary range: $100,000 to $110,000 with $15,000 sign on.
Excellent Benefits including $40K tuition reimbursement – $10K annually

Position Scope:
The Coordinator of Care is an essential component of the certified agency team. The Coordinator of Care is a Registered Professional Nurse who will manage all aspects of patient care related to services provided in the home. This would include, conducting home visits, completion of all required documentation, communication with PCP, completion of 485 and all interim orders, update medication profile, care coordination with other disciplines, review and completion of case communication notes, daily review of follow-up items and incomplete documentation items noted in HCHB, participation in case conferencing with respective supervisor.

Essential Job Duties:

• Performs a home care assessment to determine patient’s eligibility for services.
• If not eligible/appropriate for home care services COC will indicate not admitted in the system and reason for the determination.
• If appropriate for home care services, the COC will complete a comprehensive assessment utilizing HCHB.
• In conjunction with patient’s family and physician, develops and implements the Plan of Care based upon a comprehensive physical, psycho-social and environmental assessment.
• Provides skilled nursing care as described in the 485-Plan of Treatment, such as, but not limited to, wound care, injections, prepour/prefill of medications, disease management, medication management, etc..
• Orients and supervises home health aide personnel in accordance with regulatory requirements and documents accordingly.
• Evaluates the effectiveness of interventions in accordance with the plan of care.
• Identifies the need for evaluation by other disciplines such as physical therapy, occupational therapy, MSW, speech therapy and nutrition.
• Observes signs and symptoms and changes in patient’s clinical, psychological and functional status. Consults with physician regarding changes in the treatment plan.
• Educates, counsels, supervises patient and caregiver relating to disease management and medical regime.
• Documents in HCHB Clinical Software all assessments, treatments and services provided and patient response to the treatment plan.
• Case manages respective caseload which includes, but is not limited to, ongoing communication with MD, case conferencing with supervisor, obtaining updates from interdisciplinary team, completion of interim orders, updating of patient profile, conducting recertification assessments, etc.
• Contacts physician to report, clarify and/or obtain orders for; medication changes/additions, precautions, treatment, changes in visit frequencies, additional services needed, requests for supplies and equipment, plans for discharge from a service or the agency.
• Documents and completes all assessment visits within 48 hours of the assessment date.
• At the start of each workday, will review any incomplete/follow-up items upon log in to HCHB. Will immediately address and prioritize these items prior to conducting visits for the day. This may include; new SOCs, ROC, change in SOC dates, documents requiring completion, etc. In addition, the COC will check twice during the workday to see if additional follow-up/outstanding documents require attention or action.
• Seeks supervisory guidance when handling complex care patients, incidents/occurrences and environmental safety issues.
• Completes 60-day summary on recertification 485, locator 22 area.
• Regularly participates in case conferencing with supervisor and other members of the inter-disciplinary team.
• Conducts discharge planning activities and identifies when patient has achieved goals. Will communicate in advance anticipated discharge date to patient, family, physician and other members of the interdisciplinary team, as indicated.
• Attends all mandatory in-services.
• Participates in Quality Improvement activities.
• Observes principles of Infection Control and adheres to standard precautions at all times.

Requirements

• Registered Nurse in the State of New York
• Current Physical
• Vehicle needed for most territories
• 6 months RN experience clinical experience in acute, SNF, LTC, LTAC, Homecare, etc.
• Experience with EMR and HCHB a plus