RN Case Manager, Post Acute
Company: SSM Health
Location: Janesville
Posted on: May 14, 2022
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Job Description:
Coordinates patients' interdisciplinary plan of care through
assessment and evaluation of patient condition and effectiveness of
care under the direction of the attending physician by traveling to
patient homes, Community-Based Residential Facilities (CBRF),
assisted living locations, hospitals or other to meet patient and
family/caregivers, assess patient care needs, acuity in relation to
regulations of home care and/or hospice services.PRIMARY
RESPONSIBILITIESCollaborates with the patient, family and
healthcare team to develop a comprehensive plan of care based on
the unique needs of the patient. Responds to calls from patients,
family members and others, completes follow-up to address needs,
issues, or concerns. Provide skilled nursing care within the
established plan of care, including performance of tasks such as
taking vitals, performing wound care, IV care, ostomy care, blood
draws, injections, and the physical assessment of the overall
patient's medical condition. Conducts patient admissions and
routine visits.Continually evaluates the patient's condition and
the effectiveness of treatments, plan of care, medications, and
therapies. Reviews, sets-up, and administers medications as
necessary per the established plan of care. Documents visit notes,
treatments, and care. Follows visit pattern according to physicians
orders and ensures required visits are completed in a timely
manner. Ensures all documentation is timely, accurate and complete
in adherence to regulations. Collaborates, consults and
communicates with physician regarding the plan of care and changes
to patient status. Provides physician with regular updates on
progress and recommends revision of plan care, documents status and
communication in adherence with regulations. Coordinates and
communication with multi-disciplinary team members and outside
agencies as appropriate to achieve expected outcomes for patient
care and education through end of life or discharge, ensuring
accurate and complete documentation and coordination of unique care
plan. Provide instruction and direction to other nursing staff
regarding patients. Monitors and reviews the provision of care
provided, communicates concerns to supervisor. Provides instruction
and training as necessary. Reviews documentation to ensure
compliance to the plan of care.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. EDUCATIONGraduate of accredited school of
nursing EXPERIENCEOne year experience PHYSICAL REQUIREMENTSFrequent
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.Frequent
Driving.
Keywords: SSM Health, Janesville , RN Case Manager, Post Acute, Executive , Janesville, Wisconsin
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