Home Health RN Case Manager- Mequon, Brown Deer and Glendale

Major Responsibilities

• Assumes responsibility for caseloads consisting of patients in specialty areas.
• Conducts initial assessment to obtain thorough physical, social and environmental data.
• Establishes the plan of care in accordance with the physician orders and patient needs.
• Provides direct patient care and adjusts care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate.
• Provides ongoing assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated.
• tes documentation including visit assessment, OASIS, 485 and verbal orders accurately and promptly and within the standards.
• Communicates with physicians to confirm and update patients' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team.
• Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate.
• Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided.
• Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines.
• Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served, and the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to their age‑specific needs. Age‑specific information is further developed in the departmental job standards.

• Registered Nurse license issued by the state in which the team member practices.
• Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA), to be obtained within 6 months unless department leader determines it is not required.
• A valid driver's license issued by the Division of Motor Vehicles, or a driver license issued by the state of Illinois.

Associate's Degree in Nursing.

Typically requires 3 years of experience in clinical nursing.

• Excellent communication skills. Strong interpersonal skills and the ability to work with a variety of clients with patience and respect. Good organizational, analytical and problem‑solving skills.
• Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
• Proficiency in clinical skills with the ability to work under direction and make sound judgments.
• Ability to operate the necessary equipment to perform the job, i.e., FAX, computer, copier, telephone system.
• Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs.
• Displays tolerance for differences and an appreciation of multiculturalism and diversity of the patients and their families.
• Possesses and provides proof of a valid Driver License and a registered, functional car with adequate insurance coverage.

• Capable of the manual dexterity required to use and operate a variety of equipment.
• Physically able to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arms overhead.
• Able to work safely with people of various sizes and weight with diverse and complex medical conditions and physical limitations.
• Can sit, stand, walk and climb stairs for limited to prolonged periods of time to complete required paperwork, gain entry to patients’ residences, travel from assigned visits and attend a variety of work‑related…