Provides high quality nursing care to meet the needs of the patient and manages/coordinates the delivery of multidisciplinary health care services for a caseload of patients.
• Assesses the physical, social and psychological needs and environmental conditions of the patient through professional knowledge, skills of observation, interviewing, and physical examination to develop a plan of care.
• Communicates and consults with patient’s MD and follows-up on problematic situations affecting care such as abnormal clinical findings, medication discrepancies, or other factors that impact patient’s ability to comply with the plan of care.
• Manages and coordinates all aspects of assigned caseload.
• Establishes, implements, and revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members, caregivers, HHAs, etc.) based on goals mutually acceptable to the patient and significant others.
• Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching and supervision of the delivery of care to meet the needs of the patient.
• Oversees/supervises the care provided to the patient by Licensed Practical Nurses and Paraprofessionals through regular home visits in compliance with regulatory requirements.
• Assesses the patient’s condition, monitors the effect of the care plans on the patient/family health status, informs physician and other team members of changes in the client’s needs and updates the plan of treatment, as needed.
• Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient care.
• Assists patients with activities of daily living, which may require positioning, moving, transferring and lifting patients of varying weights and physical conditions, with and without assistance and as appropriate, from family members and/or paraprofessionals.
• Manages, plans, coordinates and executes the patient’s safe discharge from service.
• Ensures that physician’s orders, discharge summary and communication to team members, patient and family members adhere to regulatory requirements.
• Follows work procedures in relation to established workflows.
• Performs other related duties as needed.
Skills & Experience:
• Licensure: License and current registration to practice as a registered professional nurse in New York State required.
• Minimum of one year of clinical nursing experience.
We are an equal opportunity employer and comply with all applicable federal, state, and local fair employment practices laws. We strictly prohibit and do not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex, sexual orientation, gender (including gender identity and expression), marital or familial status, age, physical or mental disability, perceived disability, citizenship status, service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. Applications from members of minority groups and women are encouraged.