Visiting Nurse- Registered Nurse

About the role

We are seeking a Visiting Nurse (Nurse Case Manager) to serve patients throughout the Savannah area. This role is a critical part of the patient’s care team, visiting patients and facilitating appropriate providers. The Visiting Nurse (Nurse Case Manager) will travel to patients' homes, long-term care facilities, and initiate telemedicine visits to evaluate patients and provide quality healthcare.

Responsibilities

• Facilitate receiving all medical records from the patient’s primary provider and specialists.
• Review medical records.
• Complete consents with patients.
• Enroll patients in Care Management, if they meet eligibility criteria.
• Initiate a Care Management Plan of Care, if the patient is eligible.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete AWV’s to be reviewed by the provider.
• Complete cognitive impairment screenings.
• Complete Social Determinants of Health (SDoH) assessments and/or screenings.
• Complete ACP’s to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
• Provide post-discharge education.
• Evaluate for adaptive equipment and DME.
• Evaluate for safe environment.
• Evaluate for acute condition(s) or follow-up from previous visit.
• Appropriately and accurately document and log Care Management activities.
• Work in conjunction with care team to keep the patients Care Management care plans up to date.
• On-call may be required.

Requirements

• Must be a licensed nurse. Registered nurse preferred.
• Licence must be in good standing with appropriate board/issuer.
• A minimum of three (3) years clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal skills.
• Basic computer knowledge.
• Able to manage and demonstrate effective leadership skills.
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
• Able to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.