RN Care Coordinator (Snf Case Manager)

Oakwood Village has an exciting opportunity for qualified candidates to join our Prairie Ridge (East Side of Madison) senior living community facility team as a Care Coordinator. Our Care Coordinator is responsible for providing direct and indirect nursing care to residents that are admitting and discharging to and from the facility. This position is accountable to the Director of Resident Care Services in the Skilled Nursing for Oakwood Village.

This position is exempt working normal business hours, full time, Monday through Friday.

Why Work at Oakwood?

• Great competitive pay!

• 403B Retirement Plan -Paid Time Off for staff working 37.5 or more hours every two weeks

• Dental, Vision, Life insurance offered for staff working 37.5 or more hours every two weeks and medical benefit offered for those working 60 hours or more every two weeks.

• Continuing Education/Tuition Reimbursement Program

Job Responsibilities of a Care Coordinator (Not intended to be an all-inclusive list)

• Facilitates the admission process, assessment, and resident orientation upon arrival to the facility.

• Oversees the MDS assessment process, sets the assessment schedules and assures that assessments are done in an accurate and timely manner and in compliance with Federal and State regulations.

• Coordinates the care plan as according to regulatory requirements. They must ensure that important resources are made available to patients and that patient care is delivered effectively and to a satisfactory standard.

• Is responsible for coordination with nursing staff for all clinical admission tasks and assessments in electronic medical record.

• Makes daily rounds on units and collaborates with Nursing Staff and/or Social Services; reviews clinical records, and resident care plans.

• Maintains contact with the resident to assess adjustment to setting and response to treatment as needed and reports to Interdisciplinary Team as appropriate.

• Begins the discharge planning process on admission and coordinates the plan of care with the interdisciplinary team.

• Coordinates discharge care conferences within 72 hours of admission with resident, health care representative, and interdisciplinary team.

• Attends all additional resident care conferences.

• Facilitates any required resident and/or family teaching and arranges for any follow up care required after discharge in collaboration with nursing staff and Social Services.

• Attends and/or delegates to nursing staff telehealth visits. Collaborates with Unit Secretary and Social Services in scheduling of telehealth visits as appropriate.

• Collects (in conjunction with Health Information Coordinator) and evaluates outcome data including re-hospitalization rates, analyzes chart of hospitalized patients to identify trends or issues, to ensure outcomes within recommended quality measures.

• Completes a comprehensive chart review of all patients readmitted or transferred to ER and assists with communication of staff education.

• Coordinates patient and responsible party education regarding disease management with the interdisciplinary team to include medication management at the time of discharge.

• Facilitates reintegration into the community with Social Services, patient, responsible party, and post skilled facility partners to include primary physician follow up appointment, and is responsible for the recapitulation of stay.

• Serves as liaison between patient, physicians, and family members in regard to transition of care.

• Participates in in‑services and other ongoing education, as necessary. Participates in staff orientation and development programs.

• Performs other duties as assigned, including responding to an emergency event and working as a floor nurse as directed by the Director of Nursing.

DECISION MAKING

Decisions are made independently concerning assignments of resident care to LPN's and Nursing Assistants, changes of assignments, daily care of residents, preparing appropriate documentation concerning conditions of residents, and other daily activities.

INTERACTION

There is significant interaction with other departments of the facility, physicians, pharmacy, local health care providers, residents and their families.

ESSENTIAL KNOWLEDGE AND ABILITIES:

Knowledge of current nursing theory and practice, applicable State, Federal, and County laws, rules and regulations pertaining to resident care, residents' rights, and special needs of residents. Ability to provide skilled nursing care and prepare appropriate documentation regarding residents, communicate effectively orally and in writing, and interact effectively with staff, other health care providers, residents and their families. Able to fulfill physical demands of job, sensory demands (seeing and hearing), and cognitive demands (concentration, conceptualization, memorization).

TRAINING AND EXPERIENCE:

Graduation from an accredited school of nursing, valid licensure as a registered nurse in the State of Wisconsin. Must possess a valid Wisconsin driver's license. Experience in Long Term Care or as a Nurse Care Coordinator Preferred.

QUALIFICATIONS:

• Knowledge of both the State of Wisconsin regulations and the Code of Federal regulations, preferred.

• Knowledge of the RAI process and Medicare requirements, preferred.

• Ability to work in a partnership environment, which fosters effective team work in meeting the mission of Oakwood, required.

• Ability to use independent judgment and make sound decisions, required.

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