Job Description

The Home Health OASIS Admission Registered Nurse (RN) is responsible for conducting comprehensive initial patient assessments and completing the OASIS (Outcome and Assessment Information Set) documentation in accordance with Centers for Medicare & Medicaid Services (CMS) regulations and agency policies. This role ensures accurate clinical evaluation, eligibility determination, and the development of individualized, patient-centered care plans for patients admitted to home health services.

Key Responsibilities:

Initial Patient Assessments & Admissions

• Conduct comprehensive start-of-care (SOC) visits in the patient’s home environment.
• Perform thorough physical, psychosocial, functional, and environmental assessments.
• Determine patient eligibility for home health services based on clinical criteria and physician orders.
• Identify immediate care needs, safety risks, and potential barriers to care.

OASIS Documentation & Compliance

• Accurately complete all required OASIS data collection and submissions within regulatory timeframes.
• Ensure documentation reflects the patient’s true clinical status and supports the plan of care.
• Maintain compliance with CMS guidelines, Medicare Conditions of Participation, and agency policies.
• Collaborate with QA/clinical leadership to resolve documentation discrepancies.

Care Planning & Coordination

• Develop individualized, problem-focused care plans based on assessment findings.
• Collaborate with physicians, intake coordinators, therapists, and interdisciplinary team members.
• Initiate appropriate skilled services and referrals based on patient needs.
• Ensure continuity of care during admission transition.

Clinical Decision-Making & Patient Safety

• Identify acute changes in condition and escalate care appropriately.
• Provide patient and caregiver education related to diagnosis, medications, and safety.
• Implement infection control and fall prevention strategies during admission visit.

Communication & Documentation

• Communicate effectively with intake, scheduling, and clinical operations teams regarding admission status.
• Maintain timely, accurate, and complete clinical documentation in the electronic medical record (EMR).
• Participate in admission review processes and quality improvement initiatives.

Requirements

Required Qualifications:

• Current and unrestricted Registered Nurse (RN) license in the state of practice (Texas preferred if applicable).
• Minimum 1–2 years of clinical nursing experience; home health experience strongly preferred.
• Prior experience completing OASIS assessments required or highly preferred.
• Strong understanding of Medicare home health regulations and documentation standards.
• Proficiency in EMR systems and electronic documentation.

Preferred Qualifications:

• Experience with start-of-care admissions in a Medicare-certified home health agency.
• Knowledge of ICD-10 coding basics and clinical documentation improvement.
• Strong assessment, critical thinking, and time management skills.
• Ability to work independently in the field with minimal supervision.

Physical & Environmental Requirements:

• Ability to travel to patient homes within assigned service area.
• Must be able to lift, bend, stand, and walk for extended periods.
• Exposure to varying home environments and potential safety risks.

Core Competencies:

• Clinical judgment and assessment accuracy
• Regulatory compliance and documentation excellence
• Patient-centered care delivery
• Strong communication and interdisciplinary collaboration
• Time management and organizational skills