RN-Case Manager, Post Acute
Company: SSM Health
Posted on: May 7, 2022
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
- Collaborates 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
- 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 patients
medical condition. Conducts patient admissions and routine
- Continually evaluates the patients 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
- 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.EDUCATION
- Graduate of accredited school of nursingEXPERIENCE
- One year experiencePHYSICAL REQUIREMENTS
- Frequent lifting/carrying and pushing/pulling objects weighing
- 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
- Frequent use of hearing and speech to share information through
oral communication. Ability to hear alarms, malfunctioning
- Frequent keyboard use/data entry.
- Occasional bending, stooping, kneeling, squatting, twisting and
- Occasional lifting/carrying and pushing/pulling objects
weighing 25-50 lbs.
- Rare climbing.
- Frequent Driving.
Keywords: SSM Health, Janesville , RN-Case Manager, Post Acute, Healthcare , Janesville, Wisconsin
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