Certified CPR and negative TB skin test or chest x-ray
Minimum one year experience in home health, primary care clinic, or health facility
Exceptional nursing assessment skills
Analytic and critical thinker
Responsibilities
Perform and supervise comprehensive initial assessments to determine patient needs
Develop and revise individualized Plans of Care in collaboration with patients and team
Initiate nursing interventions and ensure accurate documentation
Conduct regular patient reassessments to evaluate progress and modify interventions
Coordinate interdisciplinary care and participate in case conferences
Monitor clinical outcomes, patient safety, and implement quality improvement initiatives
Train and assess competency of new clinical staff and ongoing education
Ensure compliance with nursing practice regulations and participate in audits
Benefits
Opportunity for growth and professional development
Supportive team environment focused on patient-centered care
Involvement in quality improvement initiatives
Flexible scheduling options to accommodate work-life balance
Access to ongoing training and educational resources
Full Job Description
Responsibilities:
Clinical Oversight & Care Coordination
Perform and/or supervise comprehensive initial assessments, including OASIS (if applicable), to determine patient needs and eligibility for home health services.
Develop, implement, and periodically revise individualized Plans of Care (POC) in collaboration with the patient, family/caregiver, physician, and interdisciplinary team, consistent with RN scope of practice in California.
Initiate appropriate nursing interventions and services; ensure timely and accurate physician orders, documentation, and care plan updates.
Conduct regular patient reassessments, including at mandated intervals and with any significant change in condition, to evaluate progress, modify interventions, and determine ongoing service needs.
Coordinate interdisciplinary care (PT, OT, ST, MSW, HHA, etc.) and participate in case conferences to review patient status, outcomes, and care plan effectiveness.
Monitor clinical outcomes, patient safety, and satisfaction; assist in implementing quality improvement initiatives.
Direct Patient Care (Field Work)
Provide skilled nursing care to patients in the home setting within the California RN scope of practice, including but not limited to:
Comprehensive nursing assessments and ongoing observation.
Medication management, reconciliation, and administration.
Wound care, catheter care, ostomy care, infusion therapy, and other skilled procedures as ordered.
Pain and symptom management, disease process teaching, and self-management education.
Patient and family/caregiver teaching on treatment regimens, safety, infection control, and equipment use.
Respond to changes in patient condition; implement appropriate interventions and promptly communicate significant findings to the physician and interdisciplinary team.
Ensure timely and accurate clinical documentation in accordance with agency policy, state and federal regulations, and payer requirements.
Staff Training, Education & Competency
Participate in the orientation of new clinical staff, including RNs, LVNs/LPNs, HHAs, and other field clinicians, ensuring understanding of agency policies, clinical standards, and regulatory requirements.
Develop and/or deliver ongoing in-services and educational programs focused on home health best practices, documentation standards, patient safety, infection control, and evidence-based care.
Perform competency assessments (initial and annual, and as needed) on clinical staff within the RN scope, including:
Direct observation of clinical skills in the field and/or simulated settings.
Review of clinical documentation and case management practices.
Evaluation of adherence to care plans, infection control standards, and agency protocols.
Identify learning needs and performance gaps; provide coaching, mentoring, and corrective action plans as needed, in collaboration with management.
Serve as a clinical resource for staff, offering real-time guidance on complex cases, procedures, and standards of care.
Regulatory Compliance & Quality Assurance
Ensure that all nursing services are provided in compliance with the California Nurse Practice Act, Title 22, Medicare Conditions of Participation, OSHA, HIPAA, and other applicable regulations.
Assist with internal audits, chart reviews, and performance improvement projects; implement corrective measures when deficiencies are identified.
Participate in survey readiness activities and accompany surveyors (state, accreditation, payors) as assigned.
Promote and model safe work practices, standard precautions, and infection prevention measures.
Leadership & Communication
Support the Director of Patient Care Services/Clinical Director in daily clinical operations, including staffing, case assignment, and workload balancing.
Provide input on clinical policies, procedures, and workflows to improve efficiency and quality of care.
Participate in regular staff meetings, case conferences, and leadership meetings; communicate agency goals, changes in policy, and clinical expectations to field staff.
Foster a culture of teamwork, accountability, and professional growth among interdisciplinary team members.
Serve as a liaison between clinical staff, physicians, patients/families, and office leadership, ensuring timely and effective communication.
Requirements
Current unrestricted CA RN license
Certified CPR and negative TB skin test or chest x-ray
Minimum one (1) year of documented experience required in a home health agency, primary care clinic or health facility, preferred.
Possess exceptional nursing assessment skills
Analytic/Critical thinker.
Licensed driver with valid automobile insurance
Ability to work on weekends, nights and holidays
Reliable transportation
Must be able to stand walk, squat, bend, kneel, reach, twist, push and pull. Varied assistance is required depending on the mobility of the client. Must be able to lift up to 50 pounds
