The Registered Nurse RN in Home Health provides and directs provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations and agency policies. Also, The RN Registered Nurse job coordinates total plan of care with other health care professionals involved in care, and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. All done within a Point of Care setting. Provides clinical services within the scope of practice, as defined by the state laws governing the practice of nursing, in accordance with the plan of care, and in coordination with other members of the health care team. Makes the initial and|or comprehensive nursing evaluation visit, determines primary focus of care, develops the plan of care within State specific guidelines, and submits accurate, complete, and timely documentation, per policy. Regularly evaluates and re-evaluates (as warranted by changes in condition but at least every 60 days) the patient's nursing needs. Performs patient comprehensive assessments at designated time points and develops the appropriate POC, in collaboration with physician orders. Ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source. Initiates, develops, implements and makes necessary revisions to the plan of care in collaboration with the physician and other health care professional's involved in care. Makes referrals to other disciplines, as indicated by patient's assessed need. Responds to outcome coordinator|coder and Patient Care Manager requests for clarification to OASIS assessments on the same day that the request for more information is sent. License Requirements Current RN licensure in state of practice. Current CPR certification required. Current Drivers License, vehicle insurance, and access to a dependable vehicle or public transportation