Registered Nurse

Job Description

Job Description

Clinical Care & Patient Assessment

• Conduct comprehensive in-home and telehealth nursing assessments, evaluating physical, psychosocial, and environmental factors that impact health outcomes.

• Meet members in a variety of settings that may include, but not limited to houses, group homes, skilled nursing facilities, etc.

• Perform vital signs monitoring, review medical history, complete medication reconciliation, and identify potential safety or adherence risks.

• Provide clinical nursing interventions as appropriate, including wound care, medication administration, and patient teaching.

• Identify and respond to changes in patient condition, collaborating with physicians and care teams to implement timely interventions.

• Quality delivery of clinical assessment skills and practices.

• Deliver palliative and supportive care focused on comfort, dignity, and quality of life, addressing pain, symptom management, and emotional well-being.

• Participate in transitions of care, helping patients navigate from hospital to home or between care settings safely and effectively.

• Must be comfortable having end-of-life conversations, planning, and assisting with the completion of advance directives.

Care Coordination & Case Management

• Develop, implement, and revise individualized care plans that integrate medical, behavioral, and social determinants of health.

• Serve as the clinical liaison between patients, families, providers, and community agencies to ensure seamless, coordinated care.

• Partner with physicians, advanced practice providers, social workers, and therapists to conduct interdisciplinary case reviews and panel management.

• Conduct follow-up calls, telehealth visits, and home visits to monitor progress and reinforce care plans.

• Facilitate access to resources such as hospice referrals, behavioral health support, transportation, and food security services.

Education, Empowerment, & Support

• Provide disease-specific education to patients and caregivers on conditions such as diabetes, COPD, hypertension, heart failure, and dementia.

• Educate on symptom recognition, medication safety, nutrition, exercise, and advance care planning.

• Empower patients to participate actively in self-management and care decisions.

• Offer emotional support, coping strategies, and grief counseling for patients and families facing chronic illness or end-of-life challenges.

• Must be able to speak on the sensitive nature of death and dying.

• Ability to help coordinate care plans for the patient and family.

Community Outreach & Resource Navigation

• Conduct home safety evaluations and recommend adaptive equipment or environmental modifications to enhance independence and reduce risk.

• Engage in community outreach to connect patients with social, financial, and medical resources that support well-being.

• Collaborate with outreach teams to locate and re-engage patients who are non-compliant or difficult to reach.

• Participate in community events, health fairs, and patient education programs to promote awareness of available services.

Clinical Documentation & Compliance

• Accurately document all assessments, interventions, communications, and outcomes in the Electronic Health Record (EHR) in accordance with policy and regulatory requirements.

• Maintain strict adherence to HIPAA regulations, ensuring confidentiality and data integrity.

• Track and report quality metrics, patient outcomes, and care coordination activities to support program improvement.

Professional Collaboration & Development

• Mentor and provide guidance to LVNs, Medical Assistants, and community health staff as appropriate.

• Participate in bi-weekly care team huddles, clinical rounds, and performance improvement initiatives.

• Engage in continuing education and maintaining clinical competencies relevant to community-based nursing and palliative care.

• Adapt to evolving technology platforms, documentation systems, and clinical protocols.

SKILLS & QUALIFICATIONS

• Two (2+) years of clinical nursing experience.

• One (1+) year in community health, home health, ambulatory care, population health, or palliative care, or hospice care strongly preferred.

• Strong understanding of chronic disease management, transitions of care, and social determinants of health.

• Excellent communication, interpersonal, and patient advocacy skills.

• Ability to work independently and exercise sound clinical judgment in non-traditional care environments.

• Proficiency with electronic health record (EHR) systems and Microsoft Office Suite.

• Knowledge of HIPAA and regulatory requirements for patient privacy and safety.

• Must be able to travel up to 40% within assigned geography. (Yuba City, Sutter County, and surrounding areas).

• Reliable transportation, valid driver’s license, and proof of auto insurance required.

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