Registered Nurse

Summary:

The Case Manager (RN) provides skilled nursing care to patients in their homes in accordance with agency policies and state and federal regulations. Responsibilities include implementing individualized care plans, supervising Personal Care Workers (PCWs), coordinating services, and supporting patients and families to achieve optimal health outcomes. Bilingual ability is a strong asset.

Key Responsibilities:

Clinical Care

• Conduct comprehensive physical, psychosocial, and environmental assessments.

• Develop, implement, and update individualized care plans with the interdisciplinary team.

• Deliver skilled nursing services (e.g., wound care, medication management, IV therapy, catheter care, chronic disease management, patient education).

• Monitor progress, document findings, and communicate changes to physicians and the care team.

• Ensure compliance with all regulations, policies, and professional standards.

Care Coordination

• Collaborate with physicians and interdisciplinary team members to ensure continuity of care.

• Participate in case conferences and care planning.

• Educate patients and caregivers on conditions, medications, safety, and self-management.

PCST Assessment & Documentation

• Perform PCST assessments to determine eligibility and service hours based on functional needs and medical necessity.

• Complete accurate charting, including ADL scoring and clinical justification.

• Maintain documentation per Medicaid guidelines and agency policy; update as conditions change.

Care Planning & Oversight

• Develop and revise PCS care plans aligned with client needs and PCST results.

• Conduct supervisory visits to ensure PCWs follow care plans and deliver quality care.

• Provide clinical guidance to PCWs on safe care techniques.

Client Monitoring

• Assess and monitor client health, identifying changes requiring intervention.

• Communicate significant updates to physicians and team members.

• Educate clients and families; promote independence, dignity, and safety at home.

Regulatory & Documentation

• Complete timely, accurate EMR documentation.

• Maintain compliance with all state, federal, and accreditation standards.

• Participate in audits, quality assurance, and performance improvement activities.

• Follow HIPAA and confidentiality requirements.

Professionalism & Communication

• Demonstrate cultural sensitivity and effective communication.

• Use bilingual skills when applicable to enhance care.

• Maintain professional boundaries and ethical standards.

Qualifications:

• Active, unrestricted RN license in Wisconsin.

• Minimum one year of clinical experience; home health preferred.

• Strong assessment, critical thinking, and decision-making skills.

• Valid driver’s license, reliable transportation, and auto insurance.

• Proficiency in EMR/OASIS documentation.

Physical Requirements:

• Travel to patient homes.

• Ability to lift/assist patients and stand, walk, or sit for extended periods.

• Ability to operate and train PCWs in safe use of a Hoyer lift.