Qualifications: • A current license to practice as a RN in CT. • Graduation from a State licensed and Accredited School of Nursing. • BSN degree preferred. • Must have a minimum of one-year hospital experience. • Computer proficiency required. • Ability to effectively communicate verbally and in writing. • Strong organizational and time management skills are required. Responsibilities include but are not limited to: Patient Care and Oversight of the Plan of Care • Manage and prioritize patient caseloads in accordance with physician orders and care plans • Perform comprehensive skilled assessments, including OASIS, to determine care needs and service eligibility • Develop, implement, and update individualized, patient-centered plans of care • Coordinate admissions, interdisciplinary services, and care delivery across the healthcare team • Deliver high-quality, compassionate skilled nursing care • Ensure patient safety, emergency preparedness, and prevention of re-hospitalization • Maintain regulatory, legal, and ethical compliance, including Medicare Conditions of Participation • Complete and maintain accurate, timely electronic clinical documentation • Communicate changes in patient condition and coordinate interventions promptly • Facilitate care coordination, case management, and discharge planning • Participate in interdisciplinary case reviews and outcome evaluations • Promote patient and family education, independence, and engagement Medications: • Provide oversight and ensure the safe administration of medications at admission and during each patient visit • Identify and reconcile all prescribed and over-the-counter medications, allergies, and supplements, and document accurately in the physician’s plan of care • Review potential medication side effects, interactions, and contraindications; provide education to patients and caregivers • Establish and implement individualized medication administration systems to support patient safety and adherence • Accurately document medication pre-pouring, including drug name, dosage, frequency, dates, and times when applicable • Educate patients and families on medication purpose, administration, interactions, side effects, adverse reactions, and appropriate follow-up actions • Monitor and evaluate medication effectiveness, communicate changes to the physician, and document outcomes in the medical record Supervision: • Supervises Licensed Practical Nurses (LPNs) and Paraprofessionals providing care. • Develops and updates individualized Homemaker/Companion/HHA plan of care for each patient, including all aspects of care, diagnoses, potential drug interactions/side effects, action in emergencies, etc. and enters into telephony system • Supervises HHAs in the provision of care to assure safe implementation of the plan of care and as required by regulation. • Mentors staff (nurses and paraprofessionals) and participates in their orientation as assigned Documentation: • Maintain accurate, timely, and complete clinical documentation for each patient visit, including assessments, care provided, and plans of care • Document patient and family education, instructional materials provided, return demonstrations, and patient response • Complete all required documentation in accordance with agency policies and guidelines • Record communications with external agencies and insurance providers • Prepare and submit required 10-day, 60-day, and discharge summaries • Ensure documentation complies with CHAP standards, reimbursement requirements, and applicable regulatory guidelines Team: • Collaborate with interdisciplinary team members to support coordinated, patient-centered care • Provide clinical expertise and support to team members as needed • Participate in required team, clinical staff, and case conferences • Coordinate care across disciplines to ensure integrated plans of care • Partner with intake, scheduling, and liaison staff to ensure timely admissions and care transitions • Coordinate with liaison nurse during hospital or facility stays • Participate in weekend and holiday coverage in accordance with agency requirements Educational: • Certified in CPR • Attends yearly OSHA in-service and completes annual skills validation • Identifies knowledge gaps and remedies this independently • Attends minimum 12 hours of in-services per year, including 6 hours of hospice inservice for staff caring for hospice patients • Shares information with other Agency personnel Billing: • With Intake and Billing, explores all billing sources available to the patient • Writes/communicates billing instructions to billing and other departments • Communicates with insurance case managers according to processes of each company to assure authorizations and payment for services. Follows guidelines for the provision of care under Medicare and Medicaid • Participates in pre-billing review as needed or assigned All Agency Employees Must: • Abide by HIPAA privacy practice guidelines • Abide by related agency policies and appropriate departmental procedures • Other duties and responsibilities as may be required by the agency HIPAA Security Level-all patient data