It's more than a career, it's a calling. OK-SSM Health at Home Oklahoma City Worker Type: Regular Job Summary: Coordinates, facilitates and performs interdisciplinary plan of care through assessment and evaluation of patient condition and effectiveness of care under the direction of the attending physician by traveling to patient homes, Community-Based Residential Facilities (CBRF), assisted living locations, hospitals or other to meet patient and family/caregivers, assess patient care needs, acuity in relation to policies, procedures and regulations of home care and/or hospice services. Job Responsibilities and Requirements: PRIMARY RESPONSIBILITIES Assesses and coordinates patient's discharge planning needs with members of the healthcare team. May perform point of care testing according to policies and procedures. Collaborates, consults and communicates with physician regarding the plan of care and changes to patient status. Provides physician with regular updates on progress and recommends revision of plan care, documents status and communication in adherence with regulations. Coordinates and communicates with multi-disciplinary team members and outside agencies as appropriate to achieve expected outcomes for patient care and education through end of life or discharge, ensuring accurate and complete documentation and coordination of unique care plan. Completes admission paperwork and verifies insurance information. Completes a comprehensive medical assessment by entering data into the clinical computer program. Ensures that patient assessment is completed in a timely manner. Provides skilled nursing care within the established plan of care, including performance of tasks such as taking vitals, performing wound care, IV care, ostomy care, blood draws, injections, and the physical assessment of the overall patient’s medical condition. Documents visit notes, treatments, and care. Follows visit pattern according to physicians orders and ensures required visits are completed in a timely manner. Ensures all documentation is timely, accurate and complete in adherence to regulations. Collaborates with the patient, patient’s family and healthcare team to develop a comprehensive plan of care based on the unique needs of the patient. Responds to calls from patients, family members and others, completes follow-up to address needs, issues, or concerns. Works in a constant state of alertness and safe manner. Performs other duties as assigned. EDUCATION Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE No experience required PHYSICAL REQUIREMENTS Constant use of speech to share information through oral communication. Constant standing and walking. Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of smell to detect/recognize odors. Frequent use of hearing to receive oral communication, distinguish body sounds and/or hear alarms, malfunctioning machinery, etc. Frequent driving. Frequent keyboard use/data entry. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Occasional lifting/moving of patients. Occasional bending, stooping, kneeling, squatting, twisting, gripping and repetitive foot/leg and hand/arm movements. Rare crawling and running. Work Shift: Day Shift (United States of America) Job Type: Employee Department: 1917000114 Hospice Oklahoma Scheduled Weekly Hours: 32 SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more. Create or login to your SSM Health Candidate Workday account to track your application progress and see real-time updates. Remember to keep a record of your login information to access your Candidate Workday account in the future! Current Employees & Contractors – please apply internally via the Career app on your Workday home page. Do not continue here. Visit here for more information.