RN - Speciality Case Manager / Telehealth Nurse Home Care

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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.

• Degree from an Accredited School of Nursing (BSN preferred)
• Current WI RN license
• 1-2 years of Med/Surg, Cardiac or Home Care experience
• Current/Valid WI Drivers License; plus reliable/insured vehicle