RN - Home Healthcare
Presbyterian Healthcare Services | |
United States, New Mexico, Albuquerque | |
1100 Central Avenue Southeast (Show on map) | |
May 09, 2026 | |
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Location Address: 8100 Constitution Pl NE Albuquerque, NM 87110-7643Compensation Pay Range: Minimum Offer $37.80 Maximum Offer $51.00Summary: As a Home Health RN, you'll be a patient advocate - responsible for case management of Home Healthcare patients. Our Home Healthcare team ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state.How you grow, learn and thrive matters here. Responsibilities: This role is eligible for a sign on bonus and relocation benefit! Ensures the quality and safe delivery of home health services: Completes assessments that are timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource, and spiritual needs of patients. Coordinates patient's care through collaboration with patient/care giver, multidisciplinary team, and physician/APC. Intervenes consistently and changes interventions with orders to meet changes with patient/caregiver needs. Evaluates each visit the effectiveness of interventions and the patient's response to intervention. Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care plan of care in conjunction with physician. Assures completion of required OASIS assessments according to regulations for home care and QAPI measures. Coordinates implementation of the plan of care through a multidisciplinary home care team, community resources and physician/APC. Ensures plan of care is followed and that documentation complies with regulatory requirements. Maintains a department productivity standard for visits and caseload management. Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met. Assure patients on case load are notified timely of their visits, any unplanned schedule changes, and accommodate patients preferred schedule as available. Precepts newly hired nurses, students and serves as a resource person and professional role model as needed. Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and communicated timely to the team. Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered in a timely manner per agency policy and procedures. Oversight and delegation of the plan of care within the care team as appropriate to LPN*s and CNAs. Assumes professional responsibility for current nursing practice and clinical standards of care. Participates in agency continuous quality improvement and process improvement project (PIP) activities as required. Assume other leadership roles as required by the department. Responsible for holiday coverage, select weekend coverage and evening call for agency and patient home visits as required on a rotating basis. Performs other functions as required. Caring Practices: Incorporates nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff with the aim of promoting comfort and healing and preventing unnecessary suffering. Applies The Promise and incorporates into care interactions. Applies Exceptional Patient Experience principles and incorporates into care interactions Applies respect and timely response in interactions with patient, family, health care team members Interacts with patient and family providing compassionate, non-judging, empathetic care Clinical Judgment and Action: Uses clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the patient care situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care. Critical Elements of Clinical Judgment and Action Performance Consistently uses the nursing process to structure and revise care. Anticipates, recognizes, and responds to changes in condition Accurately communicates with healthcare team members to relay changes in patient status Consistently provides care based upon need and urgency Consistently applies patient safety principles Develops, plans, and evaluate patient short- and long-term care goals. Charts problems, plans and goals appropriately in EMR Consistently follows policies, procedures, standing order sets, care bundles, core measure practices. Consistently follows red rules: Patient identification and handwashing. Seeks consultation if uncertain on how to respond to patient needs Adjusts care to establish and support care goals Integrates technology into daily care of patient by appropriate initiation of technology, maintenance, troubleshooting, and discontinuation Consistently and accurately documents care per policies & standards Patient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation. Critical Elements of Patient Advocacy Performance Maintains patient confidentiality/personal/medical information Identifies ethical and clinical issues Acts with integrated healthcare team using appropriate resources to resolve ethical/clinical issues Advocates for patient needs, values, and goals Compliance with JC Rights and responsibilities of the Individual elements Clinical Inquiry: Uses high standards and evidence-based practices along with questioning, research, and evaluation skills to provide informed and/or change practice Critical Elements of Clinical Inquiry Performance Supports process/quality improvement initiatives and incorporation into practice Follows and is informed on Department outcome measures Actively participates in changes in practice/roll outs Seeks advice and consultation on care from colleagues and interdisciplinary team Collaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomes Critical Elements of Collaboration Performance Provides and coordinates independent, interdependent, and dependent care interventions with interdisciplinary care team Selects appropriate Screenings from HED to facilitate interdisciplinary care when needed Appropriately delegates care, monitoring delegated team members care and responds as appropriate with the goal of optimizing care Interactions with care team in respectful, professional manner Facilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding. Critical Elements of Facilitation of Learning Performance Response to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice. Critical Elements of Response to Diversity Performance Uses PHS established internal resources and vendors System Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care. Utilizes internal and PHS resources to provide evidence-based care including policy, protocols, procedures, approved specialty resources Incorporates all patient safety technology, tools, protocols, communications, and initiatives to optimize a safe patient environment Deploy in the clinical environment processes to enhance care efficiency, cost containment Negotiates within the system to achieve the care needs of the patient Qualifications:
We're all about well-being, starting with yours. Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. | |
May 09, 2026