Some locations may require: • Completes clinical admissions for all Company services including, but not limited to: • Explains services to potential patients/families and addresses questions regarding patient fears, physical limitations, while putting the patient/family at ease • Presents services in an empathetic and compassionate manner • Identifies admission objections, concerns or other entry barriers and provides responses • Educates patient/family on admission requirements and addresses immediate needs • Completes informed consents and initial assessment according to regulations and Company policy • Provides information to Physicians and initiates Plan of Care to address patient's immediate needs • Initiates skilled nursing interventions to prevent complications, alleviate symptoms and maximize physical and emotional comfort • Obtains Physician orders • Completes documentation per Company policy • Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public • Communicates frequently with Admissions to ensure timely follow-up • Provides all necessary clinical communication timely using SBAR • Discusses any potential needs with after-hours staff • Obtains consents for services and arranges safe discharge in an efficient manner for referred and eligible patients while meeting productivity expectations • Obtains medical record information for the referral • Develops strong relationships with case managers, physicians, etc. Job Responsibilities: • Makes after-hours visits to patients in their home, assisted living facility, nursing home, or hospital, anywhere within the assigned affiliate(s) territory • Provides compassionate customer service to patients and families • Assesses patient/family and identifies immediate needs and appropriate nursing interventions by phone and/or during visit • Provides and manages direct care to patients and families as part of Interdisciplinary Group (IDG), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up • Demonstrates clinical skills regarding case management, application of company policy and procedure, physical assessment, intravenous therapies, pain medication titration, symptom management, and patient/family relationships • Prioritizes, consults, refers, and collaborates with other professionals to promote quality and continuity of patient/family care • Educates patient, family, caregivers and other health professionals about disease process and decline, palliative interventions, care giving, dying process, and safety practices • Reports changes in the patient's condition to appropriate members of the IDG or other health professionals • Attends patient deaths; prepares body for transport; oversees disposal of medications; and provides bereavement support • Completes documentation per policy and procedure • During times of emergencies (i.e. Hurricanes, etc.), the RN, Nights and Weekends may be required to report to work at a location designated by the company, to ensure continuity of services.