Registered Nurse (RN) – Field Clinician

The Field RN provides comprehensive, direct in-home nursing care, case management, and clinical leadership in accordance with the plan of care and physician orders. The RN completes OASIS assessments (SOC/ROC/Recert/Transfer/Discharge), develops and updates individualized care plans, performs skilled interventions, and coordinates interdisciplinary services to achieve superior clinical outcomes, regulatory compliance, and patient satisfaction.

*Schedule & Travel*

Full-time or part-time; primarily daytime hours with occasional evening/weekend or holiday coverage as needed. Local travel within the District (and nearby MD/VA if assigned). Mileage/expense reimbursement per policy.

*Key Responsibilities*

*Case Management & OASIS*

• Complete OASIS assessments (SOC, ROC, Recertification, Transfer, Discharge) accurately and on time; establish visit frequencies and measurable goals.
• Develop, implement, and update the patient’s plan of care (POC) based on clinical assessment, physician orders, and patient/caregiver goals.
• Coordinate interdisciplinary services (therapy, MSW, HHA) and ensure timely resumption of care following hospitalization.
• Monitor outcomes, risk factors (e.g., falls, wounds, medication issues), and escalate per protocol to prevent avoidable ED visits/readmissions.

*Direct Patient Care & Clinical Procedures*

• Perform skilled nursing interventions including comprehensive assessments, wound/ostomy care, catheter care, enteral feeding support, injections, IV therapy/line care (if credentialed), and disease‑management education.
• Perform medication reconciliation; administer medications as ordered; identify adverse effects or interactions and notify provider.
• Teach and reinforce self‑care techniques; use teach‑back to confirm understanding and adherence.

*Supervision & Delegation*

• Provide clinical oversight and direction to LPNs and Home Health Aides (HHAs) per scope and agency policy.
• Conduct HHA supervisory visits and competency checks; verify aide care plans and documentation.
• Review LPN documentation; ensure timely communication of status changes and adherence to POC.

*Care Planning & Coordination*

• Collaborate with physicians, hospitals/SNFs, therapists, MSW, and agency intake/staffing to ensure patient continuity and timely starts of care.
• Arrange/verify supplies and DME (wound, ostomy, catheter, infusion); document medical necessity and approvals.
• Participate in case conferences/huddles; communicate progress, barriers, and solutions.

*Documentation & EMR*

• Complete accurate, timely documentation in the EMR, including OASIS, visit notes, orders, communication logs, and coordination tasks.
• Ensure orders/consents are obtained, signed, and routed; maintain documentation that supports billing and compliance.
• Respond to QA reviews and correct deficiencies within timelines.

*Quality, Safety & Compliance*

• Adhere to RN scope of practice, agency clinical policies, infection prevention, and Medicare Home Health Conditions of Participation (CoPs).
• Protect PHI per HIPAA and minimum‑necessary standards; maintain professional boundaries and cultural competence.
• Meet timeliness standards for visits, OASIS submissions, and QA corrections; use EVV/visit verification as applicable and resolve exceptions promptly.
• Support survey readiness; participate in audits, competencies, and performance improvement activities.

*Benefits*

• Competitive pay
• Medical, dental, vision
• Paid time off and paid holidays.
• Paid Sick Leave

*Pay Range*

$90 – $120 per visit, depending on experience, certifications, and services performed.

*Qualifications*

*Required*

• Active RN license in the District of Columbia, in good standing.
• Current BLS/CPR certification (ACLS preferred for high‑acuity programs).
• 1–2+ years of recent clinical experience (home health, med‑surg, telemetry, ED, critical care, or similar).
• Proficiency with EMR systems and Microsoft 365 (Outlook, Teams, Word, Excel).
• Valid driver’s license, reliable transportation, and ability to travel to patient homes.

*Preferred*

• Home health experience with OASIS assessments (SOC/ROC/Recert/Discharge).
• Advanced wound care, ostomy, and catheter care proficiency; WCC/WOCN a plus.
• IV therapy/infusion experience; PICC/central line care (agency credentialing as required).
• Experience with EVV and home health EMRs (e.g., Axxess, Homecare Homebase, WellSky/Kinnser, AlayaCare).
• Bilingual or multilingual skills.

*Core Competencies*

• Clinical judgment and critical thinking; timely escalation to the provider.
• Patient‑centered communication and education; cultural humility.
• Organization, time management, and follow‑through in a field setting.
• Team collaboration and leadership with LPNs/HHAs and the IDT.
• Quality mindset with attention to documentation accuracy and timeliness.
• Professionalism and discretion with PHI.

*Physical & Work Environment Requirements*

• Frequent driving and care delivery in varied home environments (stairs, pets, limited space).
• Ability to stand, walk, and perform clinical tasks; occasional lifting up to 25 lbs (supplies/equipment).
• Exposure to common home and healthcare-related environmental factors; uses appropriate PPE.

*Compliance & Health Requirements*

• Background check and employment eligibility verification.
• Health clearance per agency policy (e.g., TB screening, immunizations).
• Annual competencies and mandatory trainings.

*EEO Statement*

Direct Care Home Health Services is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Note: This job description is intended to describe the general nature and level of work. It is not an exhaustive list of all responsibilities, duties, and skills required.

Pay: From $90.00 per hour

Benefits

• Dental insurance
• Health insurance
• Paid sick time
• Paid time off

Work Location: In person