Acts as a resource to employees by assisting with coordination of patient care planning and outcomes. Assists with patient scheduling for nursing visits and revisits. Schedules regular interdisciplinary team meetings on a weekly basis and assures collaboration between all disciplines to coordinate patient care planning. Educates employees on changes and/or on new material and assists with precepting new hires. Reviews quality and operational reports and data with the teams to improve patient financial and clinical outcomes. Assumes responsibility for caseloads consisting of patients in geographical/specialty areas. Conducts initial assessment to obtain thorough physical, social and environmental data. Establishes the plan of care in accordance with the physician orders and patient needs. Provides direct patient care and adjusts nursing care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate. Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated. Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines. Completes documentation including visit assessment, development of the POC, and verbal orders accurately and promptly and within the standards. Communicates with physicians to confirm and update patients' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team. Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure:

Nurse, Registered (RN) A valid driver's license issued by the Division of Motor Vehicles.

Education/Experience Required:

Bachelor's Degree in Nursing. Typically requires 5 years of experience in clinical nursing.

Knowledge, Skills & Abilities Required:

Advanced clinical and technical knowledge of home care. Excellent communication skills. Strong interpersonal skills and the ability to work with a variety of clients with patience and respect. Good organizational, analytical and problem-solving skills. Must be flexible and able to problem solve and make frequent independent decisions. Proficiency in clinical skills with the ability to work under direction and make sound judgments. Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. Ability to operate the necessary equipment to perform the job, i.e., FAX, computer, copier, telephone system. Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs. Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families. Registered Nurse license issued by the state in which the team member practices, and Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA)

Physical Requirements and Working Conditions:

Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis. Must be able to travel to all areas within the Advocate Aurora service area in all extremes of weather on all types of roads. Exposed to widely varying social and environmental conditions in patient's neighborhoods and homes. Must be willing to work occasional overtime if needed. Required to make visits to private residences which may not be accessible to people with disabilities. Will be exposed to the following hazards on a frequent basis: mechanical, electrical, chemical, blood and body fluids. Will be required to wear PPE, protective clothing and equipment as needed. Operates all equipment necessary to perform the job.

Physical Requirements and Working Conditions:

Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis. Must be able to travel to all areas within the Advocate Aurora service area in all extremes of weather on all types of roads. Exposed to widely varying social and environmental conditions in patient's neighborhoods and homes. Must be willing to work occasional overtime if needed. Required to make visits to private residences which may not be accessible to people with disabilities. Will be exposed to the following hazards on a frequent basis: mechanical, electrical, chemical, blood and body fluids. Will be required to wear PPE, protective clothing and equipment as needed. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.