Qualifications:

1. A current license to practice as a RN in CT.
2. Graduation from a State licensed and Accredited School of Nursing.
3. BSN degree preferred.
4. Must have a minimum of one-year hospital experience.
5. Computer proficiency required.
6. Ability to effectively communicate verbally and in writing.
7. Strong organizational and time management skills are required.

Responsibilities include but are not limited to:

            Patient Care and Oversight of the Plan of Care

• Manage and prioritize patient caseloads in accordance with physician orders and care plans

• Perform comprehensive skilled assessments, including OASIS, to determine care needs and service eligibility

• Develop, implement, and update individualized, patient-centered plans of care

• Coordinate admissions, interdisciplinary services, and care delivery across the healthcare team

• Deliver high-quality, compassionate skilled nursing care

• Ensure patient safety, emergency preparedness, and prevention of re-hospitalization

• Maintain regulatory, legal, and ethical compliance, including Medicare Conditions of Participation

• Complete and maintain accurate, timely electronic clinical documentation

• Communicate changes in patient condition and coordinate interventions promptly

• Facilitate care coordination, case management, and discharge planning

• Participate in interdisciplinary case reviews and outcome evaluations

• Promote patient and family education, independence, and engagement

Medications:

• Provide oversight and ensure the safe administration of medications at admission and during each patient visit

• Identify and reconcile all prescribed and over-the-counter medications, allergies, and supplements, and document accurately in the physician’s plan of care

• Review potential medication side effects, interactions, and contraindications; provide education to patients and caregivers

• Establish and implement individualized medication administration systems to support patient safety and adherence

• Accurately document medication pre-pouring, including drug name, dosage, frequency, dates, and times when applicable

• Educate patients and families on medication purpose, administration, interactions, side effects, adverse reactions, and appropriate follow-up actions

• Monitor and evaluate medication effectiveness, communicate changes to the physician, and document outcomes in the medical record

Supervision:

• Supervises Licensed Practical Nurses (LPNs) and Paraprofessionals providing care.
• Develops and updates individualized Homemaker/Companion/HHA plan of care for each patient, including all aspects of care, diagnoses, potential drug interactions/side effects, action in emergencies, etc. and enters into telephony system
• Supervises HHAs in the provision of care to assure safe implementation of the plan of care and as required by regulation.
• Mentors staff (nurses and paraprofessionals) and participates in their orientation as assigned

Documentation:

• Maintain accurate, timely, and complete clinical documentation for each patient visit, including assessments, care provided, and plans of care

• Document patient and family education, instructional materials provided, return demonstrations, and patient response

• Complete all required documentation in accordance with agency policies and guidelines

• Record communications with external agencies and insurance providers

• Prepare and submit required 10-day, 60-day, and discharge summaries

• Ensure documentation complies with CHAP standards, reimbursement requirements, and applicable regulatory guidelines

Team:

• Collaborate with interdisciplinary team members to support coordinated, patient-centered care

• Provide clinical expertise and support to team members as needed

• Participate in required team, clinical staff, and case conferences

• Coordinate care across disciplines to ensure integrated plans of care

• Partner with intake, scheduling, and liaison staff to ensure timely admissions and care transitions

• Coordinate with liaison nurse during hospital or facility stays

• Participate in weekend and holiday coverage in accordance with agency requirements

Educational:

• Certified in CPR
• Attends yearly OSHA in-service and completes annual skills validation
• Identifies knowledge gaps and remedies this independently
• Attends minimum 12 hours of in-services per year, including 6 hours of hospice inservice for staff caring for hospice patients
• Shares information with other Agency personnel

Billing:

• With Intake and Billing, explores all billing sources available to the patient
• Writes/communicates billing instructions to billing and other departments
• Communicates with insurance case managers according to processes of each company to assure authorizations and payment for services. Follows guidelines for the provision of care under Medicare and Medicaid
• Participates in pre-billing review as needed or assigned

All Agency Employees Must:

• Abide by HIPAA privacy practice guidelines
• Abide by related agency policies and appropriate departmental procedures
• Other duties and responsibilities as may be required by the agency

HIPAA Security Level-all patient data