Advanced Care at Home RN Case Manager Milwaukee, WI

Advocate Health and Hospitals Corporation•Milwaukee, WI

About The Position

The Advanced Care at Home RN Case Manager provides nursing case management to assigned patients, supporting their health status, quality of life, and ability to remain at home. The role develops therapeutic relationships across the healthcare continuum and regularly consults with Advanced Care at Home advanced practice clinicians and physicians about patient needs. The case manager assesses patients in person, recognizes changes in clinical status, adjusts care plans, coordinates services and referrals, and continually reviews care and service utilization for each patient on the caseload. The position educates patients and families about disease processes, expected trajectories, and disease management; evaluates responses to treatment, medications, and education; and communicates problems or changes in condition to providers. It collaborates with patients, families, practitioners, the interdisciplinary care team, and community agencies, and contributes to quality improvement, patient safety, and the development of colleagues. The role maintains accurate electronic health record documentation in accordance with agency standards, policies, and applicable accreditation, state, and federal guidelines. This full-time position is based in Milwaukee, Wisconsin, with a Monday–Friday daytime schedule and 40 hours per week. The role requires travel throughout the program service area, including in varying weather and road conditions, and visits to patients’ homes. Weekend, holiday, and different-shift work may be required to accommodate staffing. The work may involve adverse or unpleasant conditions while caring for the sick and lifting up to 35 pounds without assistance; patient-handling equipment and another associate are expected for specified heavier or unassisted patient lifts.

Requirements

Bachelor’s degree in Nursing.
Registered Nurse license issued by the state in which the team member practices.
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association.
Valid driver’s license issued by the Division of Motor Vehicles.
Typically, 2 years of home care nursing experience or 3–4 years of medical-surgical experience.
Proficient use of patient care equipment.
Excellent telephone, interpersonal, written communication, and documentation skills.
Computer proficiency, including the ability to use software programs used by the organization.
Good time-management and organizational skills.
Ability to travel throughout the ACAH Program service area in all weather extremes and on all types of roads.
Ability to work weekends, holidays, and different shifts as needed to accommodate staffing.
Ability to handle multiple tasks, meet short timeframes, respond quickly to patient needs, and work at a fast pace.
Ability to work in varying social and environmental conditions in patients’ neighborhoods and homes, including private residences that may not be accessible to people with disabilities.
Ability to respond to patients in a timely manner and access all areas of the unit.
Ability to lift up to 35 pounds without assistance. For patient lifts over 35 pounds or when a patient cannot assist, patient-handling equipment is expected to be used with at least one other associate when available.

Responsibilities

Develop and maintain therapeutic relationships throughout the healthcare continuum.
Communicate and consult regularly with Advanced Care at Home advanced practice clinicians and physicians about patient needs.
Assess patients’ ongoing clinical status in person and determine healthcare needs or facilitate referrals to community resources.
Use the nursing process to identify problems, recognize clinical changes, and evaluate and implement changes to care plans.
Plan, implement, coordinate, monitor, and evaluate care options and services to optimize patients’ health, quality of life, and ability to remain at home.
Support patients’ and families’ right to quality, cost-effective care and mobilize resources when situations could negatively affect outcomes.
Participate in quality and process improvement initiatives and efforts to reduce risk and improve patient safety.
Educate patients and families about disease processes, disease trajectory, and disease management, and address their learning needs.
Collaborate respectfully with peers, practitioners, interdisciplinary clinical colleagues, community agencies, patients, and families to formulate an integrated approach to care.
Use teaching, assessment, and intervention skills to provide short- or long-term case management to assigned patients.
Continuously review all aspects of caseload patients’ care, including appropriate utilization of services, and make referrals to other team members as appropriate.
Enter, complete, and update electronic health record documentation in accordance with agency and department standards, policies, and applicable accreditation, state, and federal guidelines.
Assess patient responses to treatments, medications, and teaching; adjust interventions and follow-up to meet patient needs.
Communicate problems and changes in patient condition to providers.
Contribute to an environment that supports educational growth and opportunities for nursing peers and colleagues, and demonstrate leadership and commitment to personal and others’ development.

Benefits

Paid time off programs.
Medical, dental, vision, life, and short- and long-term disability benefits.
Flexible spending accounts for eligible healthcare and dependent-care expenses.
Adoption assistance and paid parental leave.
Defined contribution retirement plans with employer match and other financial wellness programs.
Educational Assistance Program.
Career development programs.
Potential premium pay, including shift and on-call pay, based on the job.
Incentive pay for select positions.
Opportunity for annual increases based on performance.