Performs patient assessments including: biophysical, psychosocial, spiritual, cultural, and age appropriate needs of the patients, including the assessment of nutrition, pain management, and signs/symptoms of abuse or neglect in order to develop, evaluate and modify patient's plan of care in home care settings.
Develops a realistic, comprehensive patient family educational plan, using appropriate resources and methods of instruction and provides patient/family health education and coaching.
Completes accurate and timely documentation, including but not limited to the processing of physician orders, in accordance with policies and procedures. Monitors and evaluates delivery of nursing care given by team members based on patient needs and professional judgment.
Collaborates with physicians and other health care professionals regarding all aspects of patient care. Identifies need to change plan(s) of care, contacts physician and facilitates the process using care pathways, when appropriate. Contacts the patient's physician regarding changes to patient's plan(s) of care.
Obtains authorizations for visits as appropriate, ensures every visit is reimbursed. Contacts payor case managers as appropriate to discuss plan of care and facilitate authorization for plan of care. Performs ongoing chart review on case load with attention to accurateness, recertifications, verbal orders for changes in Plan of Care; ensures every visit performed is within assigned frequency; ensures that overall documentation supports coverage of service as defined by regulation or payor. Reports to supervisor when needed.
Participates in training to understand and perform patient care management to patients assigned, ongoing patient chart/record review with attention to completeness and accuracy of plan of care, comprehensive assessment, start of care, resumption's and recertification's, verbal orders for changes in Plan of Care.
Completes documentation timely and accurately with prompt response to supervisors, preceptor or others request for corrections.
Demonstrates skill and accuracy with use of clinical documentation programs. Completes competency requirements satisfactorily.
Completes training modules as directed, seeks assistance and asks questions as needed to learn and understand home health and hospice regulations, standards and practices;. Identifies when a patient may be appropriate for recertification and contact physician for orders. Follow the process for recertification and creates a new Plan of Care. Completes resumption of care appropriately and develops updated orders and goals based on assessment findings.
As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations.
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Job ID: PGM-CC-7772_R11950
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