RN-Case Manager, Home Health
Company: SSM Health
Posted on: September 15, 2021
Eligible for up to $10,000 Sign On Bonus with 2+ years
Eligible for up to $5,000 Sign On Bonus with the
At SSM Health at Home, we offer a range of services – all with
one goal: to keep our patients as safe and independent as possible
We are seeking an RN Case Manager who is flexible, autonomous
and a self-starter with strong assessment, problem solving and
computer skills. In this position you will travel to patient homes
and provide skilled nursing care to home care patients and to
coordinate the patient's plan of care for all disciplines and
services under the direction of the supervisor and physician.
Hours of work: Monday-Friday, 8:00 AM - 4:30 PM (Requires
weekday on-call and weekend/holiday rotation)
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.
- 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 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
- 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
- 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
- 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.
- Graduate of accredited school of nursing
- 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, Madison , RN-Case Manager, Home Health, Other , Reedsburg, Wisconsin
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