Transitions Home Health
RN Case Manager -
Hours: 40 hours per week 8-4:30 M-F; rotation evening/weekend/holiday/on-call
To provide skilled nursing care to home care patients and to coordinate the patient’s plan of care for all disciplines and services under the direction of the Director of nursing and physician. Works with other highly skilled clinicians through a multi- or interdisciplinary team approach.
• Travels to patient homes and provides skilled nursing care within the established plan of care.
• Provides direct patient care in there including but not limited to performance of tasks such as injections, IV, wound cares, wound vac, lab draw, PICC care, ostomy, vital signs, medication management and the physical assessment of the overall patient’s medical condition.
• Continually evaluates the patient’s condition and the effectiveness of treatments, plan of care, medications, HHA and therapies.
• Coordinates the patient’s plan of care for nursing, therapy, social services and other disciplines and services from the initial assessment to discharge under the direction of the physician.
• Conducts patient admissions. Ensures that patient assessments and reassessments are completed in a timely and accurate manner.
• Develops patient-specific goals. Evaluates outcomes of care.
• Responsible for the discharge of patients. Ensures the discharge summary is complete and accurate. Coordinates the transfer of patients to external agencies in collaboration with the interdisciplinary.
• Contacts and consults with the physician regarding the plan of care. Communicates significant changes in patient condition. Provides regular updates on progress and recommends revision of plan care.
• Recommends patient for further medical attention as needed
• Documents visit notes, treatments, and care. Records and reports symptoms and changes in patient’s condition.
• Completes and transfers data on a timely basis.
• Verifies that physician orders for all disciplines are complete, accurate and cover the care and visits provided.
• Ensures orders are obtained prior to service delivery. Documents any verbal orders and follows up to secure written orders.
• Follows visit pattern according to physician’s orders and ensures required visits are completed in a timely manner.
• Documents patient refusal of visits or care.
• Provides information, instruction and education to the patient, patient family members and caregivers in proper care. Verifies that instructions are being followed and carried-out.
• Provides instruction and direction to Home Health Aides (HHA) and Licensed Practical Nurses (LPN) staff.
• Monitors and reviews the care provided by HHAs and LPNs and communicates concerns to the Director of nursing.
• Provides instruction and training as necessary.
• Reviews documentation to ensure compliance to the plan of care.
• Completes and submits timesheets or time logs to supervisor on a timely basis which accurately document hours, mileage, travel and other time worked.
• Responds to calls from patients, family members and others and provides appropriate follow-up to address needs, issues, or concerns.
• Attends and participates in mandatory meetings, in-services, and conferences.
• Assists with ordering or supplies for patients.
• Assists with audits as requested.
• Assists with other requests not listed
• Complies with federal, state, and local legal and certification requirements by studying existing and new legislation; anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
• Contributes to team effort by accomplishing related results as needed.
Education & Experience:
Associates degree in Nursing with one year minimal home care nursing experience or any combination of education and experience that provides equivalent knowledge, skills or abilities. Prior acute care, triage, or other nursing experience may be considered instead of home care experience. Current State of Wisconsin RN licensure required. Electronic charting and data entry, CPR, Good organizational and communication skills
This position requires travel to patient homes and meeting locations.
Must maintain a valid Wisconsin driver’s license.
Must maintain an acceptable driver’s record per company policy.
Must maintain proof of current auto insurance.
Must have access to a vehicle in good working condition.
Requires evening, weekend, holiday, and on-call responsibilities.
Requires conduct of 5 visits per day in 40 hour week .
Health Promotion and Maintenance, Creating a Safe, Effective Environment, Motivating Others, Legal Compliance, Bedside Manner, Medical Teamwork, Mental Health, Pain Management, Listening, Analyzing Information , Quality Focus