Advanced Care at Home RN Case Manager Milwaukee, WI

Responsibilities

• Develops and maintains a therapeutic relationship throughout the healthcare continuum.
• Regularly communicates/consults with APC and MD Advanced Care at Home (ACAH) team regarding patient needs.
• Assesses patient’s ongoing clinical status in person to determine healthcare needs or facilitates referrals to needed community resources.
• Demonstrates the use of the nursing process as a problem-solving model.
• Recognizes changes in clinical situations, evaluates, and implements changes to the plan of care.
• Plans, implements, coordinates, monitors, and evaluates all options and services to optimize the patient’s health status, quality of life, and ability to remain at home.
• Facilitates the patient and family’s right to receive quality, cost-effective care.
• Mobilizes appropriate resources in response to situations that may negatively impact patient and family outcomes.
• Participates in quality/process improvement initiatives and efforts to reduce risk and improve patient safety.
• Educates patients and families on disease processes, trajectory, and management.
• Demonstrates customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse backgrounds.
• Commits to meeting the learning needs of patients and families, utilizing appropriate resources to achieve positive outcomes.
• Assists in creating an environment that promotes educational growth for nursing peers and colleagues.
• Demonstrates respect and understanding for peers and other clinical disciplines, participating as an effective team member to formulate an integrated approach to care.
• Demonstrates leadership behaviors and commits to the development of self and others.
• Provides long-term or short-term case management using teaching, assessment, and intervention skills.
• Conducts continuous reviews of all aspects of patient caseloads, including appropriate utilization of services, and makes referrals as needed.
• Enters, completes, and updates documentation in the electronic health record according to standards, policies, and guidelines.
• Provides ongoing assessment of patient response to treatments, medications, and teaching, adjusting interventions and follow-up as needed.
• Communicates problems and changes in condition to providers.

Qualifications

• Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA)
• Valid driver’s license issued by the Division of Motor Vehicles
• Registered Nurse license issued by the state of practice

Education

Bachelor's Degree in Nursing

Experience

Typically requires 2 years of experience in home care nursing or 3-4 years of medical-surgical experience.

Skills

• Proficient use of patient care equipment
• Excellent telephone, interpersonal, and written communication skills
• Strong documentation skills
• Computer proficiency, including software programs used by the organization
• Good time management and organizational skills
• Ability to travel within the ACAH Program service area in all weather and road conditions
• Ability to handle multiple tasks and work within short timeframes
• Ability to respond quickly to patient needs and work at a fast pace

Physical Requirements

• Ability to lift up to 35 pounds without assistance; patient handling equipment and additional associates are used for lifts over 35 pounds or when the patient cannot assist.
• Work environment includes potential exposure to adverse, hazardous, or unpleasant conditions while caring for the sick.

This job description indicates the general nature and level of work expected. It is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.