Coordinates, manages and assumes primary responsibility for a patient caseload. Develops a safe and comprehensive and integrated care plan based on the needs of the individual and the family by utilizing the nursing process which includes, assessment and identification of nursing diagnosis/problems, planning, intervention, and evaluation of outcomes. Ensures proper hospice and nursing procedure is followed.

Leads the interdisciplinary care team specific to each patient and family on their caseload. Coordinates all services and collaborates with members of the interdisciplinary team to provide consistent patient care. Arranges for and/or recommends equipment, medical supplies and other necessary items and services as indicated.

May conduct OASIS assessments for Palliative Care patient and establish and update the plan of care. May conduct hospice initial and comprehensive assessments and establish and update the plan of care.

Enters, completes and updates documentation in the electronic health record as required according to agency/department, accreditation, state and federal guidelines accurately and promptly and within the department/agency standards.

Provides on-going assessment of patient response to treatments, medications and teaching while making appropriate changes in interventions and follow-up to meet patient needs. Updates and revises POC as indicated with supportive documentation to changes. Enters orders promptly into the Electronic Health Record. Communicates problems and changes in condition to physicians, supervisor and other members of the Interdisciplinary Team.

Provides health instruction to patient and family as appropriate. Updates the primary physician as indicated and according to agency, accreditation, state and federal requirements.

Participates in regularly scheduled Interdisciplinary Team Conferences to identify and discuss a holistic approach to management of patient/family goals of care and desired outcomes.

Performs Home Health Aide supervisory visits. Supervises the licensed practical nurse. Instructs paraprofessional staff on a timely basis and in accordance with agency, state and federal regulations.

Facilitates the discharge planning process according to agency standards and utilizes interagency/system and community resources to assure continuity of care after discharge.

Responsible for continuous review of all aspects of every patient on his/her caseload to include appropriate utilization of services, ensuring continued skilled nursing/home bound criteria and/or hospice/level of care criteria are met. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medication and treatments ad prescribed by the physician.

Utilizes proper body mechanics, assistive devices and safety techniques when performing various patient positioning/repositioning and transporting duties, which require lifting, and pushing/pulling. Orients and mentors new staff as requested.

Scheduled Hours

Usual work hours are M-F 8-4:30 with occasional weekend, holiday and off shift coverage. Racine/Kenosha County.

$10,000 Sign on Bonus for External Hires

Licenses & Certifications

Registered Nurse license issued by the state in which the team member practices, and

Basic Life Support (BLS) for Healthcare Providerscertification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required, and

A valid drivers license issued by the Division of Motor Vehicles, or

Driver license issued by the state of Illinois.

Degrees

Associate's Degree in Nursing.

Required Functional Experience

Typically requires 3 years of experience in nursing that includes experiences in home health, hospice, medical/surgical, long term care, emergency care/ICU or oncology or similar related experience.

Knowledge, Skills & Abilities

Competent in the principles of deformity prevention, normal range of motion, body mechanics and body alignment; and fundamental principles of human behavior and an understanding of the effects of stress upon individuals and groups.Excellent awareness and perception skills, for the purpose of assessing a patient's needs, concerns and to recognize changes in their health condition.Excellent communication and interpersonal skills.Excellent decision making and critical thinking skills, with the ability to work independently and make sound judgments.Excellent prioritization and organizational skills.Must possess and provide proof of valid Driver License and a registered, function car with adequate insurance coverage.