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Provides skilled nursing and coordinates care to patients and family members in a residential setting through a team approach and based upon systematic evaluation as authorized by a physician.

· Observes, assesses, evaluates, and plans interventions in relation to patients’ physical and psychosocial statuses, including changes in condition and/or reactions to treatments or medications for the duration of contact with patients.

· Oversees care provided by Home Health/Hospice Aides and CNAs to assigned patients and evaluates compliance with plan of care.

· Assure continuity of care through effective communication, information exchange and case conferences with other disciplines, community health, support and social agencies.

· Provides quality care and appropriate symptom management for positive clinical outcomes and promotes optimal health and quality of life through teaching, counseling, appropriate interventions and referrals.

· Maintains accurate, current and complete patient records in accordance with Agency standards and OASIS requirements as well as knowledge of current reimbursement rules and regulations.

· Participates in team scheduling coordination and “on-call” rotation schedule as necessary to meet patient care needs by assessing and evaluating patient needs via telephone and advising or making home visits as required.

· Participates in quality improvement activities and attends in-service training as assigned.

· Performs other duties as assigned by supervisor.

Qualifications include a current RN license in the State of Montana (BSN preferred), a valid driver’s license, appropriate auto insurance, and reliable transportation. 2 years of recent acute care, home care, or hospice experience including such clinical skills as venipuncture, catheterization, wound care and/or parenteral therapy preferred.