RN - Speciality Case Manager/Telehealth Nurse Home Care (Full Time 1st shift)
Location: Milwaukee, WI (corporate headquarters) (53224)
Horizon Home Care and Hospice is seeking experienced nurses to join our top-notch Home Care team.
This field based RN Case Manager (Specialty Focused - Telehealth Coordinator) will coordinate and manage the nursing services of clients (specifically heart failure, COPD and diabetics) through development, implementation and evaluation of a plan of care, working in collaboration with the interdisciplinary team and provide services at quality levels consistent with professional standards of practice.
- In collaboration with the patient/caregiver, completes patient plan of care and submits admission paperwork within 72 hours.
- Accurately and timely performs ongoing assessments of patients as evidenced by visit documentation, follows physician orders and plan of care revisions based on assessment findings.
- Maintain statistics on disease management and telehealth program patient outcomes and satisfaction. Maintain statistics on patient demographics, visits, and any other trend data as directed by the Program Manager.
- Identify patient goals and develop a plan and implement interventions.
- Ensure goals are clearly delineated and prioritized on the patient plan of care and addressed by all team members
- Case conferencing with team members occurs regularly which includes creating PCW/HHA Care Plans, initiating and updating Plans in accordance with patient needs and Agency policy.
- Assess clinical data for telehealth patients using available software on each business day. This includes, but may not be limited to: contacting the patients, assessing data submitted by patients via telehealth equipment, conducting telephone assessments, medical record documentation of patient interventions/responses, contacting the physician.
- Plan of care is revised on a regular basis reflecting changes in patient's on going assessment and /or progress or lack of progress toward goals.
- Inform physician, clinical manager and interdisciplinary team members of changes in patient status as evidenced by Case Communication documentation.
- Audit all clinical records upon recertification and discharge to evaluate content and compliance with State/Federal regulations and Agency policy and procedure.
- Assure appropriate discharge planning occurs from the start of care by utilizing a multidisciplinary approach and appropriate documentation.
- Coordinate with Prior Authorization Nurse the patients need for continuing services and providing accurate assessment data to support ongoing service.
