Job Title: Registered Nurse (RN) Job Specialty: Home Health Job Duration: 260 Days Shift: Day - 5x8 - 9am - 5pm 40 Hours Guaranteed Hours: Not specified Experience: Two years of experience in a home setting within the last fifteen years License: Current RN Licensure in New York State Certifications: Basic Life Support (BLS) required before start date Must-Have: Recent experience conducting comprehensive assessments of patients Job Description: - Perform initial in-home pre-evaluation of patients, assessing health status, strengths, care needs, and preferences, guiding individualized long-term care service plans.- Review consumer medical documentation and health referral forms relevant to the case.- Enter evaluation data into electronic forms and transmit as required.- Document concerns, conflicting information, and any issues surfaced during the evaluation process.- Emphasize continuity of care to reduce or eliminate fragmentation, duplication, and gaps in treatment plans.- Discuss healthcare options, necessary supports, service vendor options, and waiver options with consumers.- Initiate communication between the call center and eligible consumers for managed care health plan enrollment.- Enhance communication and collaborative relationships with interdisciplinary care team members to improve care coordination and facilitate service delivery.- Collect quality review data and required documentation to support outcome measurements and record case notes into CRM.- Identify opportunities for health promotion and illness prevention.- Maintain comprehensive working knowledge of community resources, payor requirements, and network services for the target population.- Meet all standards established for this position as outlined in the corresponding annual performance criteria and bonus template.- Perform other duties as assigned by the Regional Nurse Manager or project management. General Comments: All candidates must be prepared to conduct in-field assessments and provide complete information such as aliases used, current and previous addresses, and current contact details.