RN Home Visiting Coordinator

Open Until Filled

JOB CODE: 29-1141 Salary: $56,763.20 - $85,342.40

Status: Full-time, Exempt Location: Health Services

Department: Chronic Care Department Reports To: Supervising Nurse


Conducting assessments of the patient and family for appropriateness of and acceptance to home health services. Collecting patient clinical and demographic data in order to plan home health care in coordination with the multidisciplinary team. Provide skilled nursing in a community health setting to the homebound elderly acute and chronically ill through home visits, telephone consultations and case management. Develop an awareness of resources available within the community in order to coordinate services for patients and their families. Provides supervision and oversight to licensed practical nurses.


  • Follow all protocols within Chronic Care and Saint Regis Mohawk Health Services and standing orders under the direction of the Supervising Nurse.
  • Assessment of the home for patient care and safety. Complete Patient care plans, conduct reassessments and discharges from services.
  • Arranges for delivery of durable medical equipment as needed.
  • Case manager for patients discharged from the hospital to home to assure continuity of care. delete see below
  • Working with Case Management in hospital/facility setting to help identify appropriate home care referrals ensuring a smooth transition from facility to patient’s home.
  • Ability to work independently and follow providers order for treatments, injections and all other procedures within the R.N. scope of practice.
  • Identify actual and potential health problems in the home and in the community.
  • Make referrals to appropriate agencies as indicated and consult with primary care providers for appropriate action.
  • Provide education in both individual and group sessions to assure patient understanding of condition and patient compliance with all therapeutic regimes in the office or home.
  • Participate in chart review and nursing care planning with other departments.
  • Participate in primary care nursing specific to the Chronic Care program.
  • Participate in in-service/workshops pertinent to scope of practice.
  • Prepares patients for examination and obtains specimens as indicated. Documentation in EHR.
  • Wound Care experience leading to wound care certification.
  • Participate in on-call services 24/7 for our chronic nursing Departments.
  • Works closely with the medical clinic and reports patients’ ongoing medical care.
  • Assigns patients to and provides oversight and guidance to LPN’s going into the home.
  • Completes medication refills and organizes into patient pill boxes for home use. Updates Medication Administration Records
  • Installs Lifeline and Connect America Vitals monitoring equipment. Picks up equipment when no longer required. Completes client registration forms. Monitors vitals on website and reports abnormalities to Case Managing Nurse.
  • To accept other duties as assigned.

SUPERVISORY RESPONSIBILITIES: Supervise Licensed practical nursing staff.

EDUCATION AND/OR EXPERIENCE: Registered Nurse from accredited nursing program in the United States must show Registered Nursing License from NYS and two years’ experience as a nurse in related setting, Experience in wound care and/or home visiting preferred.

OTHER SKILLS AND ABILITIES: Communication both orally, written and critical thinking skills, Mohawk language and traditions is preferred, physically able to carry out the duties of the position, and Confidentiality.

REASONING ABILITY: Must be at least 18 years of age, have and maintain a valid driver’s license with a clean drivers abstract in accordance with the Saint Regis Mohawk Tribe’s Fleet Policy. Successful candidate must pass criminal background check and submit to a drug screening.

Applicants must submit letter of interest, resume, and supporting documents (certificates, degrees, licenses). Applicants that are eligible for native preference must include Tribal Identification Card, Status Card or letter to be eligible for Native Preference. All submissions can be emailed to human.resources@srmt-nsn.gov or by mail to Human Resources, Saint Regis Mohawk Tribe, 71 Margaret Terrance Memorial Way, Akwesasne, NY 13655. Due to our network security, we are unable to open hyperlinks. Applicants will need to attach their documents as a PDF or WORD files if emailing. Applicants must clearly outline that they meet the qualification requirements on their resume.


The Saint Regis Mohawk Tribe strives to be an equal opportunity employer dedicated to the policy of nondiscrimination based on race, sex, marital status, sexual orientation, religion, national origin, age, physical disability, veteran status or any other non-job-related factor. Among qualified applicants, the SRMT will give preference to the qualified native applicant.


All positions require the successful candidate to pass a drug test for illegal substances prior to employment being confirmed.


Some positions require candidate(s) to successfully pass a criminal background check prior to beginning employment, used solely for employment related purposes. Depending on the position there maybe multiple background checks.


A list of qualified candidates is created from interviews that may be used for Emergency Hire individuals to similar positions within the Saint Regis Mohawk Tribe for a period of six months.


Testing in the applicable skills may be required as part of the interview process.


The Saint Regis Mohawk Tribe has adopted a “Vaccination Policy” that requires all Health Service employees to be “Fully Vaccinated” against the Coronavirus. Applicants are not required to disclose their vaccination status at the time of application; however, they must do so upon becoming the successful candidate. The successful applicant must submit their proof of vaccination status or they may submit a Medical Exemption form upon being notified that they are the successful candidate. At that point, the policy will apply to them as though they were already employed.