Manage 5-7 patients daily.
Assesses the physical, social and psychological needs and living conditions of the patient through professional knowledge and skills of observation, interviewing and physical examination.
Travels to patients homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient.
Acts as the coordinator of care for the multidisciplinary team by providing care to patients collaborating/making/confirming referrals to other disciplines /community agencies and ordering supplies/services and ensuring they are delivered as needed. Consults patients MD and follows-up on problematic situations affecting care such as abnormal clinical findings or medication discrepancies.
Establishes/implements/revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members) based on goals mutually acceptable to the patient and significant others.
Implements the care plan by ongoing assessment, planning, coordination, counseling, teaching and supervision & more.
License and current registration to practice as a registered professional nurse in New York State required.
Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.
Bachelors Degree in Nursing from an approved program preferred
Minimum of one year of experience in a medical/surgical environment preferred.
Bilingual in English and Spanish may be required, as determined by operational needs.
Demonstrated computer skills using Microsoft and experience with an EMR system may be required based on operational needs.