Provides high quality nursing care to meet the needs of the patient and manages/coordinates the delivery of cost effective multidisciplinary health care services for a caseload of patients consistent with VNSNY philosophy, policy, goals and objectives, and Standards of Nursing Practice. Works under moderate supervision.

• Assesses the physical, social and psychological needs and environmental conditions of the patient through professional knowledge, skills of observation, interviewing, and physical examination to develop a plan of care.    
• Understands, interprets, and implements reimbursement protocols; determines the billing source for patient care.  Consults with management on complex/unique reimbursement cases.
• Acts as the coordinator of care for the multidisciplinary team by providing and managing the care needs of patients which includes /making/confirming referrals to other disciplines/community agencies and ordering supplies/services and ensuring they are delivered as needed.  Communicates and consults with patient’s MD and follows-up on problematic situations affecting care such as abnormal clinical findings, medication discrepancies, or other factors that impact patient’s ability to comply with the plan of care. Manages and coordinates all aspects of assigned caseload.
• Establishes, implements, and revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members, caregivers, HHAs, etc.) based on goals mutually acceptable to the patient and significant others. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching and supervision of the delivery of care to meet the needs of the patient.   
• Oversees/supervises the care provided to the patient by Licensed Practical Nurses and Paraprofessionals through regular home visits in compliance with regulatory and VNSNY requirements. Assesses the patient’s condition, monitors the effect of the care plans on the patient/family health status, informs physician and other team members of changes in the client's needs and updates the plan of treatment, as needed.   
• Documents content and process of all services provided in accordance with government regulations/requirements, and VNSNY policies, practices, and procedures.  Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient care. 
• Assists patiets with activities of daily living, which may require positioning, moving, transferring and lifting patients of varying weights and physical conditions, with and without assistance and as appropriate, from family members and/or paraprofessionals
• Manages, plans, coordinates and executes the patient’s safe discharge from service.  Ensures that physician’s orders, discharge summary and communication to team members, patient and family members adhere to VNSNY and regulatory requirements.
• Participates in the orientation of selected staff through ‘buddy system’ field observation of staff and feedback to appropriate staff involved in orientation process.
• Participates in selected student programs by providing guidance, training and mentoring to students.
• Provides nursing care in accordance with VNSNY policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient care.   
• Transports and utilizes required medical equipment and supplies using VNSNY designated/supplied carrying case weighing approximately 25 – 30 lbs. to and from patient homes/care facilities
• Travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient.
• Follows work procedures in relation to established workflows. 
• Maintains productivity sufficient to meet VNSNY goals. 
• Assumes responsibility for personal professional growth through attendance at in-services, training, continued formal education and select journal readership. 
• Performs other related duties and participates in special project, as assigned.  

Licensure:  License and current registration to practice as a registered professional nurse in New York State required.  Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.

Education:  Degree in Nursing from an approved program required.

Experience for CHHA:  Minimum of one year of experience in a medical/surgical environment preferred.  Bilingual skills may be required, as determined by operational needs.

Experience for Hospice:  Minimum of one year of clinical nursing experience, including at least six months of Hospice, or Med/Surg or ICU or Emergency Dep’t or Home care, Palliative Care, Oncology or Long Term Care experience, required.  Bilingual skills may be required, as determined by operational needs. Demonstrated computer skills may be required based on operational needs.