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The Registered Nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Primary Responsibilities:

Patient Care

• Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illnesses

• Regularly re-evaluate patient nursing needs

• Uses health assessment data to determine nursing diagnosis

• Initiates and develops a Plan of Care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventative, and rehabilitative nursing care actions. Includes the patient and the family in the planning process. Makes necessary revisions as patient status and needs change

• Plans and implements patient health teaching and health counseling regarding the disease process(es), self-care techniques and prevention. Counsels and involves the patient and patients’ family in accomplishing healthcare goals, meeting nursing and related needs while promoting patient/family independence

• Re-evaluates patient nursing care needs to include continuous assessment using the OASIS Data Set at appropriate time intervals during the episode

• Assesses the patient’s condition during every home health care visit; ensures assessments are communicated to the Clinical Team Manager (CTM) on a daily basis; nursing interventions are implemented to meet patient needs and changing conditions

• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician

• Identifies patient discharge planning needs as part of the Plan of Care development and implements prior to discharge of the patient

• Assumes responsibility to coordinate all patient care

• Recognizes and reports life threatening situations and responds appropriately

• Provides information regarding Home Medical Equipment (HME) and supply needs to the CTM, in a timely manner. Utilizes equipment and supplies effectively and efficiently

• Performs care management duties for patients as assigned including: notifying the physician of changes in the patient’s condition or progress toward goals, obtaining physicians orders as needed, reassessing the patient for recertification, attending and documenting case conferences, initiating coordination of care by reporting significant findings to others on the healthcare team, and planning for notification and documenting the discharge of the patient

• Adheres to the Agency’s Standard Operating Procedures as it relates to the submission of documentation

• Documents all communications with the patient, family, physician, CTM, pharmacy, and other disciplines, as indicated on communication notes

• Prepares a written plan for the certified Home Health Aide to follow, if applicable

• Established a trusting relationship with patients, caregivers, co-workers, clinic staff members, and physicians

• Demonstrates knowledge and observance of Patient Rights and Notice of Privacy Practices

• Follows all infection control standard precautions and safety guidelines/standards as per agency policy

• Participates in educational programs and all required in-service training programs to maintain comprehensive healthcare knowledge base, as assigned by supervisor

• Complies with all Homecare Dimensions, Inc. agency’s policies and procedures. Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies. Participates in the agency’s endeavors for accreditation, licensing, and professional recognition according to state, federal, and/or CHAP requirements. Participates in the Performance Improvement Program activities of the agency and periodic review of clinical records, as assigned

Communication:

• Prepares clinical notes and updates the primary physician when necessary and at least every sixty (60) days

• Communicates with the physician regarding patient needs and reports any changes in patient condition; obtains/receives physician orders as required

• Communicates with community health related personnel to coordinate the Plan of Care

• Coordinates services and schedules with the Clinical Team Manager (CTM) and Clinical Team Coordinator (CTC/Scheduler) to include recommendations for additional home health care services for patients within twenty-four (24) hours of the Start of Care (SOC)

Additional Duties:

• Participates in on-call duties within the on-call rotation schedule, to include weekends as assigned

• Ensures arrangements for equipment and other necessary items and services are available

• Instructs, supervises, and evaluates Home Health Aide care provided every two (2) weeks

• Instructs, supervises, and evaluates Licensed Vocational Nurses every thirty (30) days.

• Maintains a daily patient case load and point of care documentation levels as per agency standards

• Requires the availability of accepting patients during business hours (8 a.m. – 6 p.m.)

• Requires updating the electronic timecard daily, as per UHG Policy

• Requires contacting patients the night before the scheduled visit to provide an arrival time within a two (2) hour window

• Requires obtaining pre-approval from direct supervisor for overtime

• Requires the ability to work flexible schedule to meet patient needs

• Demonstrates personal responsibility with regard to attendance and punctuality

• Maintains privacy and confidentiality with regard to all patient, staff, and agency information

• Demonstrates flexibility, enthusiasm, and willingness to cooperate while working with others or in place of others, as necessary

• Expresses verbal and written communication in a clear, positive, and collaborative manner

• Promotes the agency’s image by adhering to the agency’s dress code

• Performs all other related nursing duties as assigned

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School diploma or equivalent

• Graduate of an accredited school of Nursing

• Registered Nurse with an active unrestricted license to practice professional nursing in the state of Texas

• Possess and maintain current CPR certification

• 2+ years clinical experience preferable in a community home health or medical/surgical setting

• Demonstrated thorough knowledge of current nursing practice, professional standards of care, and state and federal regulations regarding home care

• Demonstrated excellent observation, verbal and written communication skills, problem solving, basic math skills, and nursing skills per competency checklist

• Ability to define problem, collect data, establish facts, interpret an extensive variety of technical, medical, regulatory instruction and deal with numerous issues to draw a valid conclusion

• Evidence of independent nursing practice in delivering nursing care

• Ability to comply with accepted professional standards and practices

• Proven basic computer skills to include: Microsoft Word, Outlook, and other e-mail systems

• Ability to prioritize and communicate objectives clearly

• Experience working with electronic medical records application

• Proven excellent verbal and written skills

• Ability to interact productively with individuals and with multidisciplinary teams

• Possess a valid Texas Driver’s License and maintain auto insurance coverage in accordance with organization requirements

• Ability to travel 100%

Preferred Qualifications:

• Bachelor’s degree in Nursing

• Bilingual (English/Spanish) language proficiency

Physical Qualifications:

• Ability to endure prolonged or considerable walking or standing; lift position or transfer patients in a proximate location; lift supplies and equipment; perform reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing, functional or corrected, to perform required nursing skills

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.