HH Field Nurse

Communication

• Professionally and clearly communicates with patients, families, providers, and team members.
• Critical
• Thinking: Applies assessment findings to plan and adjust care interventions effectively.
• Compliance
• Awareness: Ensures documentation and practice comply with CMS, Joint Commission, and IDPH Standards.
• Time
• Management: Efficiently prioritizes caseload to meet patient needs and regulatory requirements. Physical Requirements Frequent walking, standing, bending, and lifting up to 25 pounds. Ability to navigate patient homes of varying layouts and conditions. Manual dexterity for medication administration, wound care, and documentation tasks. Visual and auditory acuity are sufficient to assess patients and communicate effectively. Working Conditions Field-based, traveling to patient homes and occasionally other care sites. Exposure to home environments with varying safety and hygiene conditions. Flexibility to work evenings or weekends for urgent visits as assigned. Direct interaction with patients, families, and interdisciplinary care team. Patient Assessment and Care Conducts initial patient assessments (RNs only), including physical, psychosocial, and functional evaluation, within CMS timeframes. Develops and implements individualized care plans in collaboration with the Nursing Case Manager, Director of Nursing, and therapy staff. Monitors patient status through ongoing assessments, vital signs, laboratory results, and response to interventions. Identifies changes in condition, complications, or emergent situations and communicates promptly to physician, Nursing Case Manager, or Director of Nursing. Assesses patient and caregiver ability to perform self-care, administer medications, and adhere to treatment plans. Clinical Skills and Procedures Provides skilled nursing services including but not limited to wound care, medication administration, IV therapy, catheter care, injections, and tracheostomy care as permitted by Illinois nursing scope of practice. Performs and interprets diagnostic tests (e.g., blood glucose, urinalysis) and reports abnormal results to the appropriate provider. Administers medications safely, adhering to physician orders, agency policies, and state/federal regulations. Collaborates with therapy staff to ensure integration of nursing and rehabilitative interventions. Patient Education Educates patients and caregivers regarding disease management, medications, nutrition, infection control, and home safety. Provides training on self-care skills, including ostomy care, wound dressing changes, and the use of medical equipment. Assists patients and families in understanding their plan of care, goals, and expected outcomes. Reinforces patient adherence to prescribed treatments, therapies, and lifestyle modifications. Documentation and Compliance Completes all required documentation in the electronic health record (EHR) accurately, completely, and in compliance with CMS, Joint Commission, and IDPH standards. Documents on all assessments, interventions, patient responses, and communications with providers and caregivers. Ensure documentation is audit-ready and supports billing and quality reporting requirements. Participates in internal audits and provides data to Nursing Case Manager, Director of Nursing, and QAPI Coordinator as needed. Interdisciplinary Collaboration Communicates patient status, progress, and concerns to Nursing Case Manager, therapy staff, physician, and other care team members. Participates in interdisciplinary team (IDT) meetings and case conferences to coordinate patient-centered care. Ensures seamless communication between disciplines and caregivers to prevent gaps or duplication of services. Coordinates with ancillary services (lab, pharmacy, durable medical equipment) to meet patient needs efficiently.

Requirements: Valid unrestricted RN license Reliable transportation and valid driving insurance