("home health RN" OR "visiting nurse" OR "field nurse") AND (OASIS OR SOC OR "start of care" OR "plan of care" OR HCHB OR WellSky)

Qualifications and Skills

Active, unrestricted Indiana RN license (compact accepted)
Nursing degree (Associate or Bachelor’s in Nursing preferred)
Home health, field-based nursing, or RN case management experience strongly preferred
Hands-on clinical skills: wound care, IV/infusion, drains, G-tube and patient education
Strong care coordination background (care plans, transitions of care, community resources)
Comfortable working independently in the field with strong time management
Proficient documentation skills; home health documentation systems (HCHB/WellSky or similar) preferred
Valid driver’s license and ability to travel locally between visits

Responsibilities (Registered Nurse Case Manager):

Conduct comprehensive in-home/community assessments for high-risk patients/members
Develop, implement, and reassess individualized care plans and goals
Coordinate transitions of care with physicians, discharge planners, social workers, and community resources
Provide skilled nursing support as needed, including wound care, IV therapy, drains, and G-tube care per plan of care
Provide patient/caregiver education, reinforce treatment plans, and support medication adherence
Document clinical findings, interventions, and outcomes accurately and on time
Identify and address non-clinical barriers (transportation, housing, access to services) to improve compliance
Track clinical/functional outcomes and escalate changes in condition appropriately
Participate in rotating weekend on-call coverage per schedule