341,589 Transitional Care Nurse jobs in the United States

Transitional Care Nurse

30345 Atlanta, Georgia Longleaf Hospice

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Job Description

Job Type

Full-time

Description

Longleaf Hospice and Palliative Care is locally owned with offices located in Atlanta, Covington and Roswell, offering end-of-life care to those with life limiting illnesses in the communities we serve. We believe that this very special care is best provided by professionals who live and work in the community they serve. At Longleaf Hospice and Palliative Care, we integrate and address the diverse, seen and unseen needs of patients and their families.

The Transitional Care Nurse provides direct nursing care to patients, care coordination and education to patients, families and staff in general inpatient units in accordance with established policies, procedures, and protocols. This position involves patient assessment, establishment of an individualized plan of care, discharge planning and communication with the hospice physician to meet patient/caregiver needs.

SHIFT: 7 ON / 7 OFF; 7:00AM - 7:00PM, EVERY OTHER WEEK

RESPONSIBILITIES:
  • Completes general inpatient (GIP) admissions, collaborating with the hospital physician and the Hospice physician to assist in determining the patient's clinical eligibility for hospice care
  • Makes visits to assess GIP patients daily while patient is in the hospital
  • Participates and plans discharge for those GIP patients that will be transitioned home with hospice, assisting with and completing appropriate paperwork as needed
  • Provides education regarding home hospice care and home palliative care to patients that are in the hospital
  • Provides education to the hospital staff regarding hospice and palliative care
  • Implements and monitors patient care plans
  • Monitors, records and communicates patient condition as appropriate
  • Serves as primary coordinator of all disciplines for well-coordinated patient care
  • Participates in bi-weekly interdisciplinary group (IDG) meetings
  • Assesses needs of patient and family and provides education and support based on age, culture and willingness to learn
  • Performs home hospice admissions as needed
  • Pronounces patients and performs other routine nursing visits when requested
  • Participates in Quality Assessment Performance Improvement (QAPI) program and Hospice sponsored in-services
  • Performs job duties in accordance with Nurse Practice Act
  • Other duties as assigned

Requirements

  • Licensed as a registered nurse in the state of Georgia
  • Graduate from an accredited school of nursing
  • Minimum of five (5) year's nursing experience
  • Minimum of two (2) years' experience in hospice/home care preferred
  • Certified Hospice and Palliative Care Nurse (CHPN) preferred
  • Critical thinking skills and decisive judgment required
  • Works under minimal supervision
  • Ability to work in a stressful environment required
  • Good verbal and written communication and problem-solving skills required
  • Responsible valid driver's license
  • Reliable, insured, automobile for making home visits required
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Transitional Care Nurse

90009 Riverside, California MLK Community Hospital

Posted 8 days ago

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Job Description

Date Posted:

7/28/2025

Job Code:

Tran Care Nur

Location:

MLK Community Hospital & Foundation

Address:

1680 E. 120th St.

City:

Los Angeles

State:

CA

Country:

United States of America

Category:

Care Management/Social Services

Pay Rate Type:

Hourly

Salary Range (Depending on Experience):

$46.82 - $72.57

If you are interested, please apply and send your resume to

POSITION SUMMARY

The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patient's continuity of care upon discharge.

ESSENTIAL DUTIES AND RESPONSIBILITIES

* Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
* Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
* Assess identified cases and utilize the information and available benefits/resources to assist the patient, family/caregiver and provider.
* Document all activities specific to interventions for patients contacted in the electronic medical record.
* Coordinates services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
* Assesses patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC, community resources, primary care provider, disease management, or other services.
* Promote the mission and core values of MLKCH.
* Document each call with all pertinent information along with interventions performed in a call log.
* Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
* Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
* Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
* Has authority to add or extend services as needed to prevent readmission to MLKCH.
* May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
* Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
* Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
* Must utilize Translator assistance devices as needed to improve communications with patients and families.
* Work with management to identify and vet potential post-acute service providers, as well as complete site visits to skilled nursing facilities with management to ensure MLK funded patients are receiving all necessary post-acute services.
* Perform other duties as assigned.

POSITION REQUIREMENTS

A. Education

* BSN required.
* CCM or ACM certification within 2 years of hire.

B. Qualifications/Experience

* Three (3) years of experience in Care Management either acute care or telephonic Care Management/Disease Management.
* Current California Nursing license.
* Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association.
* Valid unrestricted CA Driver's License and valid proof of vehicle insurance.
* Prior case management experience in an acute care setting, medical office or health advice RN preferred.
* Bi-lingual Spanish preferred.

C. Special Skills/Knowledge

* Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
* Must be customer service driven and be resourceful while utilizing high level of critical thinking skills.
* A team player that can follow a system and protocol to achieve a common goal
* Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.

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MLKCH Video
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Transitional Care - Nurse Practitioner

61801 Urbana, Illinois Carle Health

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Job Description

Overview Carle Health is seeking a Nurse Practitioner to join our Transitional Care Clinic (TCC) at Carle Foundation Hospital in Urbana, Illinois. Opportunity Details Typical schedule 10 hour/ 4 days per week Provides health assessment for patients directed toward returning to a state of wellness, establishing the need for intervention, evaluating responses to and outcomes of therapy, and following a mutually agreed upon treatment plan. Ensures documentation of care is complete and accurate. Communicates with other health professionals, families, and referral agencies regarding health status and needs of particular patients or patient groups. Serves as a role model in the enhancement of nursing practice and professional conduct following professional practice guidelines. Responsible for nursing care delivery by patient care support staff. Perform assessments on patients referred to the TCC and determine eligibility for the program. Place orders for scheduling patients in the TCC. Complete full assessments and provide ongoing patient care and management while the patient is under the responsibility of the Transitional Care Clinic. Place appropriate follow-up orders for patients evaluated in the TCC. Monitor patient improvement and response to therapy over the 30-day post-hospital period. Coordinate return of the patient responsibility to their Primary Care Provider Case management Home visits for appropriate TCC patients within 60 mile radius Education Requirements: Master's Degree in Nursing Two years of experience as an APN in a primary care clinic or hospital setting preferred Licensure/Certification Requirements: Current Illinois registered nurse license and advanced practice nurse licensure Basic Life Support (BLS) and APN National Certification About Our Community Champaign-Urbana has been defined as a micro-urban community, meaning we have many of the amenities of a much bigger city, with the feel of a smaller town. Almost equidistant to Chicago, St. Louis and Indianapolis for fun weekends away, the area offers excellent schools, a great downtown scene, the University of Illinois, Big 10 sports and an exciting college town atmosphere, including Krannert Center for the Performing Arts. About Us Find it here. Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health. Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: Compensation and Benefits The compensation range for this position is $55.13-$71.67/hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate's experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits
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Transitional Care - Nurse Practitioner

61801 Urbana, Illinois Carle Foundation Hospital

Posted 8 days ago

Job Viewed

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Job Description

Overview Carle Health is seeking a Nurse Practitioner to join our Transitional Care Clinic (TCC) at Carle Foundation Hospital in Urbana, Illinois. Opportunity Details Typical schedule 10 hour/ 4 days per week Provides health assessment for patients directed toward returning to a state of wellness, establishing the need for intervention, evaluating responses to and outcomes of therapy, and following a mutually agreed upon treatment plan. Ensures documentation of care is complete and accurate. Communicates with other health professionals, families, and referral agencies regarding health status and needs of particular patients or patient groups. Serves as a role model in the enhancement of nursing practice and professional conduct following professional practice guidelines. Responsible for nursing care delivery by patient care support staff. Perform assessments on patients referred to the TCC and determine eligibility for the program. Place orders for scheduling patients in the TCC. Complete full assessments and provide ongoing patient care and management while the patient is under the responsibility of the Transitional Care Clinic. Place appropriate follow-up orders for patients evaluated in the TCC. Monitor patient improvement and response to therapy over the 30-day post-hospital period. Coordinate return of the patient responsibility to their Primary Care Provider Case management Home visits for appropriate TCC patients within 60 mile radius Education Requirements: Master's Degree in Nursing Two years of experience as an APN in a primary care clinic or hospital setting preferred Licensure/Certification Requirements: Current Illinois registered nurse license and advanced practice nurse licensure Basic Life Support (BLS) and APN National Certification About Our Community Champaign-Urbana has been defined as a micro-urban community, meaning we have many of the amenities of a much bigger city, with the feel of a smaller town. Almost equidistant to Chicago, St. Louis and Indianapolis for fun weekends away, the area offers excellent schools, a great downtown scene, the University of Illinois, Big 10 sports and an exciting college town atmosphere, including Krannert Center for the Performing Arts. About Us Find it here. Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health. Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: Compensation and Benefits The compensation range for this position is $55.13-$71.67/hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate's experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits
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Transitional Care Nurse - Full Time Days

90009 Los Angeles, California Martin Luther King, Jr. Community Hospital

Posted 3 days ago

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Job Description

If you are interested, please apply and send your resume to

POSITION SUMMARY

The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patient's continuity of care upon discharge.

ESSENTIAL DUTIES AND RESPONSIBILITIES

* Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
* Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
* Assess identified cases and utilize the information and available benefits/resources to assist the patient, family/caregiver and provider.
* Document all activities specific to interventions for patients contacted in the electronic medical record.
* Coordinates services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
* Assesses patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC, community resources, primary care provider, disease management, or other services.
* Promote the mission and core values of MLKCH.
* Document each call with all pertinent information along with interventions performed in a call log.
* Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
* Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
* Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
* Has authority to add or extend services as needed to prevent readmission to MLKCH.
* May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
* Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
* Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
* Must utilize Translator assistance devices as needed to improve communications with patients and families.
* Work with management to identify and vet potential post-acute service providers, as well as complete site visits to skilled nursing facilities with management to ensure MLK funded patients are receiving all necessary post-acute services.
* Perform other duties as assigned.

POSITION REQUIREMENTS

A. Education

* BSN required.
* CCM or ACM certification within 2 years of hire.

B. Qualifications/Experience

* Three (3) years of experience in Care Management either acute care or telephonic Care Management/Disease Management.
* Current California Nursing license.
* Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association.
* Valid unrestricted CA Driver's License and valid proof of vehicle insurance.
* Prior case management experience in an acute care setting, medical office or health advice RN preferred.
* Bi-lingual Spanish preferred.

C. Special Skills/Knowledge

* Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
* Must be customer service driven and be resourceful while utilizing high level of critical thinking skills.
* A team player that can follow a system and protocol to achieve a common goal
* Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.

#LI-YD1

MLKCH Video
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Pediatric Transitional Care Nurse - STAT/Float RN

08110 Pennsauken, New Jersey BAYADA Home Health Care

Posted 16 days ago

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Job Description

**Come for the Flexibility,** Stay for the Culture ( Home Health Care was founded on the principle that health care gets better when clients get better care at home-the place they most want to be. Delivering care is our highest priority and greatest joy.
We care for people of all ages, diagnoses, and acuity levels, giving you the chance to explore and put your skills to work. Many clients require advanced care such as tracheostomy and ventilator management. We offer paid training to prepare you for the unique and rewarding environment you will provide care in, prioritizing your skillset confidence and knowledge.
**We are looking for RNs with pediatric trach and vent experience to become a part of our High Acuity Pediatric Team to help new clients transition from hospital to home and cover critical STAT openings. We offer specialized training, 24/7 clinical support and premium pay.**
**BAYADA Offers Our RNs** :
+ One on one care
+ Flexible self-scheduling options
+ Electronic documentation
+ In-depth paid training and shadowing with award-winning simulation labs
+ Short commute times - we match you with cases near your home
+ 24/7 on call clinical support
**Available RN Shifts:**
+ 8, 10 or 12-hour shifts
+ 1st, 2nd, or 3rd shift
+ PRN, Part-Time, or Full-Time
**RN Field Benefits Include:**
+ Weekly pay every Thursday
+ PTO & sick time
+ Medical, Dental, and Vision benefits
+ Company-paid life insurance
+ Employee Assistance Program
+ Public Service Loan Forgiveness Partner
+ 401K
+ Preventive Care Coverage for ALL employees (PRN included)
Pay: $32/hr - $50/hr
**Apply now to join our team!**
NER-SJ-RX
**As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates.**
BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here ( .
BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
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Transitional Care Registered Nurse 37.5

New York, New York Wyckoff Heights Medical Center

Posted 5 days ago

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Job Description

The Transitional Care Nurse works as a part of the interdisciplinary team, as well as with community agencies, to ensure post-discharge collaboration in meeting patient's needs as determined by the social determinants of health screening. The TCN ensures that comprehensive care in the community is available for the patient in the post-hospital discharge period, with the goal of preventing readmission.

Union: NYSNA

Grant Funded, 1115 Waiver

Monday- Friday

9am-5PM

Requirements:
  • Current RN licensure in New York State
  • Bilingual ( English & Spanish )
  • 2 years of Med-Surg, ED & Community Health experience required.
  • BSN required
  • MSN preferred
  • BLS & ACLS

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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Transitional Care Registered Nurse 37.5

New York, New York Wyckoff Heights Medical Center

Posted 5 days ago

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Job Description

The Transitional Care Nurse works as a part of the interdisciplinary team, as well as with community agencies, to ensure post-discharge collaboration in meeting patient's needs as determined by the social determinants of health screening. The TCN ensures that comprehensive care in the community is available for the patient in the post-hospital discharge period, with the goal of preventing readmission.

Union: NYSNA

Grant Funded, 1115 Waiver

Monday- Friday

9am-5PM

Requirements:
  • Current RN licensure in New York State
  • Bilingual ( English & Spanish )
  • 2 years of Med-Surg, ED & Community Health experience required.
  • BSN required
  • MSN preferred
  • BLS & ACLS

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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Transitional Care Team Nurse

75215 Dallas, Texas MGA Homecare

Posted today

Job Viewed

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Job Description

Company Description

MGA Homecare has been providing Private Duty Nursing, Skilled Nursing Visits, Occupational Therapy, Physical Therapy, and Speech Therapy services within the home and community-based setting for over a decade. In 2022 MGA has opened its doors to MGA Behavior Therapy which offers Applied Behavior Analysis (ABA) and early behavior intervention for pediatric patients with autism spectrum disorder (ASD) and other developmental disabilities.

We aim to help our patients and their families by delivering high-quality clinical care in the comfort of their homes. Our goal is to make the lives of our patients and their families easier by demonstrating compassion and integrity at the heart of everything we do. By bringing individualized attention and support throughout every home. MGA Homecare is proudly serving the states of Arizona, Colorado, North Carolina, Tennessee, Texas, and Washington, and are here to be a resource for patients and their families.

Job Description

This role reports directly to the Director of Operations and is responsible for transitioning pediatric patients being discharged from the hospital to home for the first time. The position involves caring for patients across the Dallas metroplex and providing coverage until a permanent caregiver is assigned. Once a permanent caregiver is in place, the role will transition to supporting the next patient being discharged home.
  • Provide nursing care and assist in transitioning patients from hospital to home.
  • Assist with hospitals and agency to facilitate hospital discharge and prevent re-hospitalization.
  • Assist with care coordination with patient care team.
  • Provide education to patient and family caregivers as identified.
  • Train new permanent nurses when identified.
  • Meet the new families at the hospital and help set expectations prior to discharge.
  • Help assist with office New hire training classes
  • Help assist with office clinical tasks as needed
  • Provide PRN nursing coverage in the Dallas metroplex area

Qualifications
  • Current state license as a Registered Nurse, BSN preferred.
  • Minimum of two years of nursing experience in a Home Health or Acute setting preferred.
    • Trach and Vent experience
    • NICU/PICU experience preferred but not required.
  • Current CPR card and Current health certificate as applicable.
  • Current state driver's license, reliable transportation and automobile insurance.
  • Attention to detail and time management skills
  • Effective problem-solving and conflict resolution
  • Good organization and effective communication

Additional Information

Benefits are available to eligible employees on the first of the month after 30 days of employment and include:
  • Health, Dental & Vision Coverage
  • Health Savings Accounts (HSA-available if enrolled in a high deductible plan)
  • Flexible Spending Accounts (FSA & LPFSA)
  • Dependent Care Reimbursement Accounts (DCRA)
  • Employee Assistance Program (EAP-available if enrolled in Health plan)
  • 401(k) retirement plan
  • Paid Time Off (PTO)
  • 100% Company Paid Basic Life Insurance (if enrolled in Health plan)
  • Voluntary Life Insurance
  • Short & Long-Term Disability
  • Critical Illness/Accident Insurance
  • Hospital Indemnity Insurance
  • Identity Protection Plan
  • Legal Care Plan
  • Pet Discount Program

All your information will be kept confidential according to EEO guidelines.

#IND456-TX-N
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Dialysis Transitional Care Registered Nurse - RN

46202 Indianapolis, Indiana Fresenius Medical Care North America

Posted today

Job Viewed

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Job Description

_A Transitional Care Unit (TCU) helps ease patients into dialysis. The first weeks of dialysis involve a great deal of adjustment, along with increased risk of hospitalization and mortality. As a TCU nurse, you will help patients feel better and make more informed decisions about their care, including choice of treatment modality-in-center or at-home dialysis._

**PURPOSE AND SCOPE:**

The professional registered nurse Home Therapies RN CAP 2 may be an entry level designation into the Clinical Advancement Program (CAP) for new employees who meet the RN CAP 2 criteria or attained through advancement from RN CAP 1. This position is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. This may include delegation of appropriate tasks to direct patient care staff including but not limited to RNs, LVN/LPNs and Patient Care Technicians. As a member of the End Stage Kidney Disease (ESKD) health care team, this position participates in decision-making, teaching, leadership functions, and quality improvement activities that enhance patient care outcomes and facility operations.

**PRINCIPAL DUTIES AND RESPONSIBILITIES:**

All duties and responsibilities are expected to be performed in accordance with Fresenius Kidney Care policy, procedures, standards of nursing practice, state and federal regulations.

+ Performs all essential functions under the direction of the Supervisor and with guidance from the Educator, Preceptor or in collaboration with another Registered Nurse.

+ Performs ongoing, systematic collection and analysis of dialysis data for assigned patients and documents in the patient medical record, makes adjustments or modifications to treatment plan as indicated and notifies Supervisor or physician as needed.

+ Assesses, collaborates and documents patient/family's basic learning needs to provide initial and ongoing education to patients and family.

+ Directs and provides, in collaboration with the patient, home care partner, direct and ancillary patient care staff, all aspects of the provision of safe and effective delivery of dialysis therapies to assigned patients.

+ Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness.

+ Initiates or assists with emergency response measures.

+ Serves as a resource, leader, coach, mentor and role model for new and incumbent employees by setting examples of appropriate behavior, work habits and attitudes towards patients, co-workers, supervisors and the company at the facility and area level.

+ Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections.

+ Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team.

+ Ensures patient awareness related to transplant and treatment modality options.

+ Assists in the identification, evaluation, selection and education of Home Dialysis candidates and Home Partners.

+ Performs assessment and identifies barriers of the Home Dialysis candidate's home environment and partner/ family readiness and ability to perform dialysis treatments in the home.

+ Trains home dialysis patients and / or Home Partners on the safe, effective operation and maintenance of all Home Dialysis equipment and treatment supplies through a formal standardized Home Dialysis Training Program.

+ Participates in education and quality improvement projects at the facility and area level as directed by Supervisor.

+ May serve as a Preceptor to new employees.

+ Required to complete CAP requirements to either maintain or advance.

+ Performs all other duties as assigned by Supervisor.

**PHYSICAL DEMANDS AND WORKING CONDITIONS:**

The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

+ The position provides direct patient care that regularly involves heavy lifting, moving of patients and assisting with ambulation. Equipment aids and/or coworkers may provide assistance.

+ This position requires frequent, prolonged periods of standing and the employee must be able to bend over.

+ The employee may occasionally be required to move, with assistance, machines and equipment of up to 200 lbs., and may lift chemical and water solutions of up to 30 lbs. as high as 5 feet.

+ The work environment is characteristic of a health care facility with air temperature control and moderate noise levels.

+ May be exposed to infectious and contagious diseases/materials.

+ Rotates coverage with other licensed home therapy staff as assigned to ensure reliable and adequate coverage.

+ Position requires participation in on-call rotation, night, weekend, holiday or as defined by individual program needs.

+ The position may require travel to training sites, other facilities and patient homes.

+ May be asked to provide essential functions of this position in other locations including patient's home with the same physical demands and working conditions as described above.

+ Day to day work includes desk work, computer work, interaction with patients, facility/hospital staff and physicians.

**SUPERVISION:**

Assigned oversight of RNs, LPNs/LVNs, Patient Care Technicians and Home Therapies Care Team Assistants as a Team Leader or designated Nurse in Charge, after meeting all the following:

+ Successful completion of all FKC education and training requirements for new employees.

+ Must have a minimum of 3 months experience home dialysis therapies as a RN.

**EDUCATION and LICENSURE:**

+ Graduate of an accredited School of Nursing.

+ Current appropriate state licensure.

+ Current or successful completion of CPR BLS Certification

+ Must meet the practice requirements in the state in which he or she is employed.

**EXPERIENCE AND REQUIRED SKILLS:**

+ Entry level for RNs with a minimum of 2 years or more of Nephrology Nursing experience within the last 2 years as a RN.

**EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity**

**Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.**

"

**EOE, disability/veterans**
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  30. gavel Government & Non Profit
  31. emoji_events Graduate
  32. health_and_safety Healthcare
  33. beach_access Hospitality & Tourism
  34. groups Human Resources
  35. precision_manufacturing Industrial Engineering
  36. security Information Security
  37. handyman Installation & Maintenance
  38. policy Insurance
  39. code IT & Software
  40. gavel Legal
  41. sports_soccer Leisure & Sports
  42. inventory_2 Logistics & Warehousing
  43. supervisor_account Management
  44. supervisor_account Management Consultancy
  45. supervisor_account Manufacturing & Production
  46. campaign Marketing
  47. build Mechanical Engineering
  48. perm_media Media & PR
  49. local_hospital Medical
  50. local_hospital Military & Public Safety
  51. local_hospital Mining
  52. medical_services Nursing
  53. local_gas_station Oil & Gas
  54. biotech Pharmaceutical
  55. checklist_rtl Project Management
  56. shopping_bag Purchasing
  57. home_work Real Estate
  58. person_search Recruitment Consultancy
  59. store Retail
  60. point_of_sale Sales
  61. science Scientific Research & Development
  62. wifi Telecoms
  63. psychology Therapy
  64. pets Veterinary
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