I. Position: Registered Nurse (RN) Care Coordinator
II. Status: Full Time, Salaried
III. Reports to: PAS RN Supervisor
IV. Position Summary: Responsible for the supervision of personal care workers and the delivery of personal care services to consumers. Work duties include home visits, consumer assessments, development of appropriate plans of care, and supervision of and performance evaluation of personal care workers.
V. Position Expected Hours of Work: Typical hours are full time 40 hours, Monday through Friday, 8:00AM through 4:30PM, however there may be some variability in the weekly schedule due to consumer need driven by compliance as well as by agency need. Must also be available for on-call services on a rotating, as-needed basis. Staff is expected to be able to work in the office, remotely, or a hybrid of both, during regular business hours. This is a salaried position; as such, a minimum of 40 or more hours weekly may be required to complete job duties
VI. Essential Functions of the Position:
A. Review, comprehend, and adhere to IndependenceFirst’s policies including those on quality and performance as well as to State of Wisconsin Statutes s. DHS 105.17 (Personal Care Providers) and s. DHS 107.112 (Personal Care Services) as well as to WI Administrative Code Chapter N, specifically Standards of Practice for Registered Nurses N 6.03.
B. Evaluate the need for service. Refer consumers to other services as appropriate. Assessment to include consumer’s environment (social and physical), functional level and pertinent cultural factors and community supports as well as nursing diagnosis.
C. Obtain written orders from consumer’s physician. These orders are to be renewed once every 3 months unless the physician specifies that orders annually are appropriate or when consumer’s needs change, whichever occurs first.
D. Develop plan of care for consumer, giving full consideration to consumer’s preferences for service arrangements and choice of personal care workers. Interpret the plan to the personal care workers and include a copy of the plan in the client’s health record. The plan
of care shall be based on the RN Care Coordinator’s visit to the consumer’s home and shall include: 1- review and interpretation of the physician’s orders; 2- frequency and anticipated duration of service; 3- evaluation of the consumer’s needs and preferences; and 4- assessment of the consumer’s social and physical environment, including family involvement, living conditions, the consumer’s level of functioning, and any pertinent cultural factors such as language.
E. Review of the plan of care, evaluation of the consumer’s condition, and supervisory review of the personal care worker shall be made by the RN Care Coordinator at least every 60 days. The review shall include a visit to the consumer’s home, review of the personal care worker’s daily written record in advance of the visit, and discussion with the physician of any necessary changes in the plan of care.
F. Promptly notify consumer’s physician, other appropriate medical personnel, and/or legal representative of any significant changes observed or reported in the client’s condition.
G. Maintain proper medical and service records and complete timely documentation in accordance with policies, laws, and guidelines. This documentation includes notation of all phone calls, in-person visits including nursing supervisory visits, assessments, quality assurance visits, plans of care, physician orders, personal care worker assignments, coordination of care, discharges, and other pertinent items of record. Discharge paperwork must be completed within 30 days of discharge.
H. Supervise personal care workers according to written plans of care. At least every 50-60 days provide supervisory review of personal care worker services in the consumer’s home and provide ongoing training needs and evaluation of competencies of personal care workers. Supervision includes intermittent face-to-face contact between supervisor and personal care worker and regular review of personal care worker’s work – including review of daily timesheets, annual performance evaluations, and documentation of training of delegated tasks including medically oriented tasks – by RN Care Coordinator. Give the personal care worker written instructions about the services to be performed and arrange for an appropriate person to demonstrate to the personal care worker how to perform the services. Evaluate the competency of the person care worker to perform the services.
I. Maintain documentation related to supervision of personal care workers. Monitor time and service reporting mechanisms for personal care workers and instruct the workers on their use.
J. Comply with, train personal care workers in, and enforce all infection control and prevention policies and procedures.
K. Provide payment source with necessary documentation within specified deadlines to approve and maintain service.
L. With RN Training and Assessment Coordinators, assist with training of new RN Care Coordinators which may include having them shadow work for a day.
M. Attend training sessions, conferences, and outreach activities as required.
N. Coordinate schedules and services for consumers in accordance with Independent Living Philosophy of consumer-controlled care with support staff in PAS department. Provide advocacy and support for the Independent Living Philosophy to all PAS staff and consumers.
O. Other duties as assigned by supervisor or department director.
VII. Professional Qualifications:
A. Current licensure as a registered nurse under Wis. Stat. § 441.06.
B. At least one year of supervisory or administrative experience required.
C. Training and experience in the provision of personal care services or in a related program.
D. Experience in personal care, home health, hospice, or rehabilitation preferred.
E. Excellent communication skills, especially written and verbal communication skills.
F. Proficient knowledge of and experience in the general use of computers and internet.
G. Experience with and knowledge of Wisconsin Medicaid system preferred.
H. Flexibility in the work environment and ability to adapt to changing department needs.
I. Transportationally mobile or able to arrange own transportation as consumer home visits are located throughout entire service area.
J. Knowledge of applicable Federal, State and local laws related to community-based health care.
K. Ability to conduct home visits in environments that may or may not be accessible.
L. Bilingual English and Spanish, Hmong, Russian, Arabic, or other fluency preferred.
M. Must meet caregiver background check requirements under s. 50.065, Statutes, and ch. DHS 12.
VIII. Work Environment:
A. Work environment is generally performed in an office setting with minimal to moderate noise level as well as in consumers’ home environments.
B. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Registered Nurse Home Health Care