Horizon Home Care & Hospice
RN - Speciality Case Manager / Telehealth Nurse Home Care
Honored to be recognized as a 7-time Top Workplace - APPLY TODAY to join our growing organization!To some people, home is a place. To others, it's a feeling. To us, it's whatever our patients need it to be, wherever they are. Horizon is a home care and hospice provider built on a foundation of care that celebrates the human spirit and the desire for security, comfort and compassion. We make a loving difference in the lives of our patients and families in offering our wide breadth of services. Our expertise is second to none, allowing us to give our patients the best care available.
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