Community Care Nurse - Weekend

Description Job Summary

• Within an Interdisciplinary Team (IDT) setting, the Community Care Nurse – Weekend is responsible for promoting and maintaining the health of LIFE Pittsburgh Participants in the community during peak weekend hours. This position provides in-person clinical assessments, post-hospital discharge follow-up, urgent illness evaluations, and scheduled weekend home visits. The role works collaboratively with the Weekend On-Call Registered Nurse to support high-quality telephonic triage, timely field response, and continuity of care. This position supports participant safety, reduces unnecessary emergency department utilization, and enhances weekend clinical responsiveness within the community setting.
• Essential
• Functions:
• Demonstrates and reflects a commitment to the mission and core values of LIFE Pittsburgh to support the elderly in maintaining their dignity and independence in the community.
• Conducts post-hospital discharge assessments to ensure safe transition to home and adherence to discharge plans.
• Performs in-home clinical evaluations for acute illness, changes in condition, and urgent participant concerns.
• Completes scheduled weekend home visits as assigned.
• Collaborates closely with the Weekend On-Call RN to determine appropriate course of action following telephonic triage.
• Utilizes strong clinical reasoning and critical thinking to assess participant status and determine necessary interventions.
• Notifies PCP, or IDT members of changes in participant condition, abnormal findings, medication issues, or other significant concerns.
• Coordinates care with hospitals, skilled nursing facilities, EMS, pharmacies, and other contracted providers as appropriate.
• Provides participant and caregiver education regarding medication management, disease processes, safety precautions, and treatment plans.
• Assists in development and implementation of Participant comprehensive assessment and plan of care.
• Documents assessments, interventions, communications, and outcomes thoroughly and accurately in accordance with LIFE Pittsburgh policies and regulatory requirements.
• Supports efforts to reduce avoidable emergency department visits through timely in-person assessment and intervention.
• Provides services promptly, exercises tact, patience, and courtesy at all times and conducts themselves in a professional manner with Participants, families, co-workers and external contacts.