Registered Nurse Case Manager - Home Care - Fond du Lac & Dodge Counties

Job Summary The registered nurse plans, organizes and directs/coordinates home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. Duties & Responsibilities Patient Care Develops a written plan of care for each patient on caseload; Updates and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s). Assesses patient’s condition, initiates plan of care, re-evaluates and updates as necessary. Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care; Provides skilled nursing care. Provides patient, caregiver, and family counseling. Provides patient and caregiver education. Prepares clinical notes. Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care. Obtains all necessary physician orders and collaborates with physician as patient’s needs dictate. 75% of all charting to be done in the patient’s home. Attends case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc. Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. Communication Prepares clinical notes and updates the primary physician when necessary and at least every sixty days. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required. Communicates with community health related persons to coordinate the care plan. Additional Duties Participates in the agency’s quality assessment and performance improvement program and home health agency-sponsored in-service training. Participates in holiday rotation and on-call duties as defined by the on-call policy and agency requirements. Ensures that arrangements for equipment and other necessary items and services are available. Instructs, supervises, and evaluates home health aide care and LPN care provided every two (2) weeks per state and agency regulations. Supervises Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs), and/or Home Health Aids (HHAs)/Certified Nursing Assistants (CNAs), as directed. Participates in all mandatory meetings, training, and in-service education. All weekend/holiday visit documentation must be completed by the following business day by 8:00 AM. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job. The employee may be requested to perform job‑related tasks other than those stated in this description. Job Requirements (Education, Experience, Knowledge, Skills & Abilities) Must have graduated from an approved school of nursing and be licensed in the State of Wisconsin. Minimum of two years of experience, at least one of which is in the area of public health or home care nursing is preferred. Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order. Self‑directed and able to work with minimal supervision. Demonstrates excellent observation, problem solving, verbal and written communication skills; nursing skills per competency checklist. Shows ability to organize and prioritize workload independently. Management experience not required. Responsible for supervising home health aides. Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills. #J-18808-Ljbffr Preceptor-Home-Health-and-Hospice