Overview: As a Home Health RN, you'll be a patient advocate - responsible for case management of Home Healthcare patients. Our Home Healthcare team ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state.Work Schedule:Full Time: 0.9 FTE or 36 hours/weekShift: DaysSign on and relocation bonuses available for qualified candidates.How you grow, learn and thrive matters here.Educational and career development options, including tuition and certification reimbursement, scholarship opportunities.Staff Safety - a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern.Shift differentials for nights and weekends.Differentials for higher education, certifications and various lead roles.Malpractice liability insurance. Interested in learning more : Text or schedule directly with me by clicking here! Responsibilities: Ensures the quality and safe delivery of home health services:Completes assessments that are timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource, and spiritual needs of patients.*Provides skilled nursing care services by planning, organizing, directing, coordinating, evaluating, and documenting all aspects of nursing care in accordance with physician/APC plan of care. Coordinates patients care through collaboration with patient/care giver, multidisciplinary team, and physician/APC.Intervenes consistently and changes interventions with orders to meet changes with patient/caregiver needs.Evaluates each visit the effectiveness of interventions and the patients response to intervention.Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care plan of care in conjunction with physician. Assures completion of required OASIS assessments according to regulations for home care and QAPI measures.Coordinates implementation of the plan of care through a multidisciplinary home care team, community resources and physician/APC.Ensures plan of care is followed and that documentation complies with regulatory requirements.Maintains a department productivity standard for visits and caseload management.Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met.Assure patients on case load are notified timely of their visits, any unplanned schedule changes, and accommodate patients preferred schedule as available.Precepts newly hired nurses, students and serves as a resource person and professional role model as needed.Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and communicated timely to the team.Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered in a timely manner per agency policy and procedures.Oversight and delegation of the plan of care within the care team as appropriate to LPNs and CNAs. Assumes professional responsibility for current nursing practice and clinical standards of care.Participates in agency continuous quality improvement and process improvement project (PIP) activities as required.Assume other leadership roles as required by the department. Responsible for holiday coverage, select weekend coverage and evening call for agency and patient home visits as required on a rotating basis.Performs other functions as required.Critical Elements of Caring Practices Performance Caring Practices: Incorporates nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff with the aim of promoting comfort and healingand preventing unnecessary suffering. Applies The Promise and incorporates into care interactions. Applies Exceptional Patient Experience principles and incorporates into care interactions Applies respect and timely response in interactions with patient, family, health care team members Interacts with patient and family providing compassionate, non-judging, empathetic careClinical Judgment and Action: Uses clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the patient care situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care. Critical Elements of Clinical Judgment and Action Performance Consistently uses the nursing process to structure and revise care. Anticipates, recognizes, and responds to changes in condition Accurately communicates with healthcare team members to relay changes in patient status Consistently provides care based upon need and urgency Consistently applies patient safety principles Develops, plans, and evaluate patient short- and long-term care goals. Charts problems, plans and goals appropriately in EMR Consistently follows policies, procedures, standing order sets, care bundles, core measure practices. Consistently follows red rules: Patient identification and handwashing. Seeks consultation if uncertain on how to respond to patient needs Adjusts care to establish and support care goals Integrates technology into daily care of patient by appropriate initiation of technology, maintenance, troubleshooting, and discontinuation Consistently and accurately documents care per policies & standardsPatient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation. Critical Elements of Patient Advocacy Performance Maintains patient confidentiality/personal/medical information Identifies ethical and clinical issues Acts with integrated healthcare team using appropriate resources to resolve ethical/clinical issues Advocates for patient needs, values, and goals Compliance with JC Rights and responsibilities of the Individual elementsClinical Inquiry: Uses high standards and evidence-based practices along with questioning, research, and evaluation skills to provide informed and/or change practice Critical Elements of Clinical Inquiry Performance Supports process/quality improvement initiatives and incorporation into practice Follows and is informed on Department outcome measures Actively participates in changes in practice/roll outs Seeks advice and consultation on care from colleagues and interdisciplinary teamCollaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomes Critical Elements of Collaboration Performance Provides and coordinates independent, interdependent, and dependent care interventions with interdisciplinary care team Selects appropriate Screenings from HED to facilitate interdisciplinary care when needed Appropriately delegates care, monitoring delegated team members care and responds as appropriate with the goal of optimizing care Interactions with care team in respectful, professional mannerFacilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding. Critical Elements of Facilitation of Learning Performance Self: Completes all required learning modules, programs in specified time Self: Uses available resources within system to enhance own continuous learning Self: sets and achieves learning and performance goals yearly Self: Consults, teaches, supports continuous learning with colleagues Self: Actively seeks learning/mentorship Patient: Assess patient's learning style, readiness to learn, challenges to learning and adapts Patient education to meet needs Patient: Incorporates patient in learning about diagnosis(es), care management, medications using appropriate verbal and written communication tools/resourcesResponse to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice. Critical Elements of Response to Diversity Performance Provides communication/ medical interpretation services for population served based upon language preference Consistently provides care to population served with appreciation to diversity elements as designated above Consistently communicates and documents patient diversity needs Uses PHS established internal resources and vendorsSystem Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care. Critical Elements of Systems Thinking Performance Utilizes internal and PHS resources to provide evidence-based care including policy, protocols, procedures, approved specialty resources Incorporates all patient safety technology, tools, protocols, communications, and initiatives to optimize a safe patient environment Deploy in the clinical environment processes to enhance care efficiency, cost containment Plan, maneuver, and deliver services/technology that are available within the system to meet the care needs of the patient Negotiates within the system to achieve the care needs of the patient Qualifications: Associate Degree in NursingRegistered Nurse - NMMinimum one year acute care experience within the last 3 years.Hospice or home care experience preferred.Basic typing competency Must have current driver's license and auto insurance.BLS required at time of hire Benefits: Presbyterian exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system comprised of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 13,000 employees - including more than 1,200 providers and nearly 3,500 nurses.Our health plan serves more than 640,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.#RN123 Maximum Offer for this position is up to: USD $51.00/Hr. Compensation Disclaimer: The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.