Coordinates, manages and assumes primary responsibility for a patient caseload. Develops a safe and comprehensive and integrated care plan based on the needs of the individual and the family by utilizing the nursing process which includes, assessment and identification of nursing diagnosis/problems, planning, intervention, and evaluation of outcomes. Ensures proper hospice and nursing procedure is followed.

• Leads the interdisciplinary care team specific to each patient and family on their caseload. Coordinates all services and collaborates with members of the interdisciplinary team to provide consistent patient care. Arranges for and/or recommends equipment, medical supplies and other necessary items and services as indicated.
• May conduct OASIS assessments for Palliative Care patient and establish and update the plan of care. May conduct hospice initial and comprehensive assessments and establish and update the plan of care.
• Enters, completes and updates documentation in the electronic health record as required according to agency/department, accreditation, state and federal guidelines accurately and promptly and within the department/agency standards.
• Provides on-going assessment of patient response to treatments, medications and teaching while making appropriate changes in interventions and follow-up to meet patient needs. Updates and revises POC as indicated with supportive documentation to changes. Enters orders promptly into the Electronic Health Record. Communicates problems and changes in condition to physicians, supervisor and other members of the Interdisciplinary Team.
• Provides health instruction to patient and family as appropriate. Updates the primary physician as indicated and according to agency, accreditation, state and federal requirements.
• Participates in regularly scheduled Interdisciplinary Team Conferences to identify and discuss a holistic approach to management of patient/family goals of care and desired outcomes.
• Performs Home Health Aide supervisory visits. Supervises the licensed practical nurse. Instructs paraprofessional staff on a timely basis and in accordance with agency, state and federal regulations.
• Facilitates the discharge planning process according to agency standards and utilizes interagency/system and community resources to assure continuity of care after discharge.
• Responsible for continuous review of all aspects of every patient on his/her caseload to include appropriate utilization of services, ensuring continued skilled nursing/home bound criteria and/or hospice/level of care criteria are met. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medication and treatments ad prescribed by the physician.
• Utilizes proper body mechanics, assistive devices and safety techniques when performing various patient positioning/repositioning and transporting duties, which require lifting, and pushing/pulling. Orients and mentors new staff as requested.

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We pride ourselves on taking care of our people. And not just our patients—we mean you, too. We help each other live well. When you work at Aurora, you get the chance to work with a dedicated team that’s as passionate about the work as you are. Here, you’ll find limitless opportunities for ongoing learning, career advancement, competitive compensation and a stable work environment. But more than that, you have the opportunity to change lives—including your own.

Diversity and inclusion matters at Aurora. We celebrate our differences and nurture an environment where everyone feels included. We know that when we reflect the communities we serve, when we embrace differences and bring our whole selves to work every day, we are working as one to build a healthier tomorrow for everyone. Aurora supports a safe, healthy and drug-free work environment through criminal background checks and pre-employment drug testing. We maintain a smoke-free environment at all our locations. We are an equal opportunity employer.