RN - Case Manager - Home Care Oak Creek

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RN - Case Manager - Home Care Oak Creek
(Full Time 1st shift)
Location:
Oak Creek, WI(53154)

Horizon Home Care and Hospice is seeking experienced nurses to join our top-notch Home Care team.  
As a RN Case Manager you will coordinate and manage the intermittent services of a client 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.
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.
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.
#LI-DNP
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