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RN Case Manager, Home Health

SSM Health

Location Fond Du Lac, WI 54935
Department WI-St. Agnes Hospital Home Care & Hospice
Posted 5 days ago -
Type: Full-Time Permanent
Reference ID: 11424512

Description

PRIMARY RESPONSIBILITIES

  • Ensures compliance with Condition of Participation (CoP) discharge planning.
  • Identifies and escalates gaps/barriers related to inpatient and observation length of stay.
  • Assesses patients at high risk for readmission. Identifies root cause for readmission. Develops plan and collaborates with multidisciplinary team regarding discharge planning to next level of care.
  • Participates with other members of team regarding opportunities for improvement in standard work.
  • May also be responsible for: utilization management process, ED case management process, admission process, and act as a case manager liaison with post acute providers (skilled nursing facilities, rehab, home health, etc.).
  • Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service.
  • As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model.  Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations.
  • Works in a constant state of alertness and safe manner.
  • Performs other duties as assigned.

EDUCATION

  • Graduate of accredited school of nursing

EXPERIENCE

  • Three years' acute care experience

PHYSICAL REQUIREMENTS

  • Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
  • Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
  • Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
  • Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
  • Frequent keyboard use/data entry.
  • Occasional bending, stooping, kneeling, squatting, twisting and gripping.
  • Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
  • Rare climbing.

SIGN ON BONUS AND BENEFITS ELIGIBLE!

At St. Agnes Hospital Home Care & Hospice, we offer a range of services – all with one goal: to keep our patients as safe and independent as possible at home.

We have an opportunity for a RN Case Manager who is flexible, autonomous and a self-starter with strong assessment, problem solving and computer skills. In this position you will travel to patient homes to evaluate patients, develop treatment plans and effectively communicate with others to ensure appropriate and comprehensive care.

Hours of work: Monday-Friday, 8:00am-4:30pm, 32 hours per week (Requires on-call and weekend/holiday rotations)

SPECIAL REQUIREMENTS

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.

Requires conduct of 20 visits/week, 4-5 visits/day or 1.66 hours/visit (based on a 8 hour work day, 32 hour work week) pending census and staffing.

Assesses, develops, plans, implements, and evaluates patients discharge planning needs to next level of care in collaboration with interdisciplinary team.

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