**Job Title:** Registered Nurse (RN) **Job Specialty:** Home Health **Job Duration:** 260 days **Shift:** 8 Hours **Guaranteed Hours:** N/A **Experience:** Minimum of two (2) years of experience in a home setting within the last ten (10) years. **License:** Current RN Licensure in the state **Certifications:** Basic Life Support (BLS) required before the start date **Must-Have:** - Recent experience conducting comprehensive assessments of patients - Ability to conduct hybrid tele and in-field assessments - Willingness to sign a Conflict of Interest form - Ability to review health status questions and make evaluations and determinations based on UAS criteria - Strong communication and organizational skills - Ability to work independently and manage multiple complex tasks simultaneously **Job Description:** - Perform initial in-home pre-evaluations of patients, including evaluation of health status, strengths, care needs, and preferences - Guide development of individualized long-term care service plans - Review consumer medical documentation and health referral forms, as relevant - Enter evaluation data into electronic forms and transmit as required - Document concerns, conflicting information, and issues surfaced during the evaluation process - Emphasize continuity of care to reduce or eliminate fragmentation, duplication, and gaps in treatment plans - Discuss healthcare options, support needs, and service vendor options with consumers - Initiate communication between the Call Center and eligible consumers for enrollment into a managed care health plan - Enhance communication and collaborative relationships with interdisciplinary care team members - 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 knowledge of community resources, payor requirements, and network services for the target population - Meet standards established for this position as outlined in the annual performance criteria and bonus template - Perform additional duties as assigned by the Regional Nurse Manager or other project management All candidates must be comfortable conducting in-field assessments and providing all required personal and contact information.