We are seeking a compassionate and experienced Registered Nurse (RN) to join our Certified Home Health Agency (CHHA) team. The CHHA RN is responsible for providing and coordinating multidisciplinary healthcare services for patients in the community. This role works closely with physicians and interdisciplinary team members to implement and monitor individualized plans of care.
The ideal candidate is skilled in home health nursing, documentation, and patient care coordination, and is comfortable traveling to patient homes within the assigned service area.
Pay: Starting at $105,000/year
Provide and coordinate patient care that is cost-efficient and reimbursable under the patient's insurance plan.
Conduct initial assessments, case openings, and ongoing patient evaluations
Travel to patient homes or facilities to provide direct nursing care.
Complete in-person OASIS assessments reflecting accurate clinical and functional patient status.
Utilize diagnosis coding skills to accurately rate acuity of diagnoses within OASIS documentation.
Evaluate patient diagnoses and collaborate with physicians and supervisors to determine the appropriate primary diagnosis.
Establish and update individualized plans of care based on patient needs and interdisciplinary team input.
Monitor patient progress and adjust care plans as needed.
Educate patients and families on disease management, self-care techniques, and prevention strategies.
Care Coordination
Coordinate services among the multidisciplinary care team, including PT, OT, home health aides, and physicians
Participate in weekly PPS meetings to review patient progress, service frequencies, and discharge planning.
Ensure adherence to physician-ordered service frequencies and duration.
Communicate regularly with therapy staff and other care team members.
Documentation & Compliance
Complete 485 physician orders in accordance with insurance authorization and OASIS scoring.
Document all patient services, progress notes, and communications in the electronic health record.
Maintain accurate documentation of home health aide supervision and care plans.
Ensure all documentation is completed accurately and in a timely manner
Home Health Aide Supervision
Supervise aides providing personal and health care services through home visits.
Maintain and review aide care plans with aides and patient families.
Document weekly supervision of aide services.
Case Management & Program Participation
Manage an assigned patient caseload.
Facilitate patient admissions and discharges from the program.
Participate in staff orientation and training as needed.
Maintain productivity standards aligned with agency goals.
On-Call Responsibilities
Participate in rotating 24-hour on-call coverage with other nurses.
Respond to patient calls and document all on-call communications in the EHR.
Carry a cell phone and respond promptly to all calls during on-call shifts.
Assume holiday on-call coverage as assigned.
Additional Responsibilities
Perform community outreach and maintain communication with hospitals and referral sources.
Complete other duties and special projects as assigned.
Strong clinical nursing skills in home health care
Knowledge of Medicare PPS system and split billing
Experience with OASIS documentation and its impact on reimbursement
Diagnosis coding proficiency
Excellent care coordination and documentation abilities
Strong organizational and prioritization skills
Computer proficiency and experience with electronic health records
Ability to work independently and collaboratively within a team
Active Registered Nurse (RN) license in New York State
Graduate of an accredited nursing program ( BSN preferred)
Minimum 1 year of CHHA experience preferred
Minimum 1 year of LTHHCP experience preferred
Valid driver's license and ability to travel to patient homes
This position requires the ability to:
Travel to patient homes including walk-ups, apartment buildings, and private residences
Work in varied home environments
Stand, walk, bend, reach, and climb stairs
Lift up to 50 pounds unassisted and up to 325 pounds with assistive devices
Drive or utilize public transportation within the assigned service region
Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions without compromising patient care.
All employees must comply with New York State health requirements, including:
Pre-employment health assessment
Annual health assessment
Compliance with applicable immunization and health regulations
Cobble Hill LifeCare™ is a health care system providing services to benefit older adults, the chronically ill, and those who are disabled or debilitated from disease or a hospital stay.
Cobble Hill Health Center: Our rehab and nursing facility offers the highest standards of care and professionalism with a warm atmosphere.
Your Choice At Home: Home care services including skilled nursing care, therapy, and home health aids right to your own home.
