Home Health Registered Nurse

Chose ANS as Your Next Employer as a Home Heath Registered Nurse (RN) Case Manager

Job Title: Home Health Registered Nurse Case Manager
FLSA Status: Exempt
Department: Home Health
Reports To: Director of Nursing
Area: Milwaukee County

Position Summary: The Registered Nurse (RN) Case Manager serves as a direct service provider within ANS Home Health. The RN Case Manager plans, organizes and coordinates the care of all assigned cases.  The RN Case Manager, in consultation with other disciplines/professionals, select outcome goals and skilled interventions. The RN Case Manager effectively use agency and community resources and direct services to meet the needs of clients and their families within their homes and communities.

Essential Job Functions:This list of duties and responsibilities is not all-inclusive and may be expanded to include other duties and responsibilities as management may deem necessary from time to time.

  • Maintains working knowledge of current home health coverage guidelines, admission criteria, documentation requirements, coding guidelines and care planning.
  • Accepts referral and contacts potential client within 24 hours of receipt of referral.
  • Conducts admission assessment visits with the client/family with the objective of defining needs, eligibility and appropriateness of the level of care available to them through the agency.
  • Determines client eligibility for admission and re certification based on admission and re certification guidelines, and regulatory requirements suitability/adaptability/safety of the client’s home for homecare delivery.
  • Completes initial home visit; introducing services, admission criteria, process for determining client eligibility and for obtaining required consents when eligibility is confirmed.
  • Completes an accurate, initial comprehensive head to toe assessment (OASIS) of client and family to determine home care needs and obtains a history of current and previous illness (es).
  • Assess the client/caregiver willingness/ability/barriers to learn client care techniques and for achieving independence in care; documents client/family response to teaching.
  • Develops home health aide/personal care worker care plan, as applicable.
  • Establishes appropriate primary and secondary diagnoses based on client assessment and focus of home health care
  • Develops plan of care (485), in conjunction with physician, client and family incorporating appropriate skilled interventions, and necessary medical supplies/equipment and ancillary/specialty services to achieve outcome/discharge goals.
  • Initiates the plan of care and related nursing interventions; conducts goal-oriented visits; ensures other nursing team members have information needed for continuity of care and continued progress.
  • Explains procedures and treatments to client to gain cooperation, understanding and allay apprehension.
  • Completes observation, assessment and evaluation regarding appropriateness of and response to care.
  • Conducts home visits as assigned, assessing the client’s condition, progress toward goals, providing client care, teaching and other skilled interventions as ordered by physician
  • Provides teaching and reinforces previous teaching, assess and documents response to teaching.
  • Regularly re-evaluate client’s nursing needs, review and instruction of meds, home safety assessment and teaching and pain assessment, as part of nursing visit.
  • Maintains awareness of holistic needs of client.
  • Records significant changes in condition or reactions and promptly contacts physician and Director of Nursing
  • Performs ongoing home health aide/personal care worker oversight, revises aide/PCW care plan based on client progress; supervises aide every 14 days if receiving skilled services and every 60 days for non -skilled clients
  • Supervises LPN participation in client’s plan of care and performance of skilled interventions every 30 days.
  • Advocates for the client as required.
  • Prepares clinical notes that documents observations and the care provided at the time cares are provided per agency time frames.
  • Obtains/receives physician orders as requirement for treatment changes; communicates new/changed orders to appropriate team members.
  • Ensures the availability of equipment/supplies and other necessary items to support care plans, uses equipment/supplies per plan of care/insurance and documents per agency policy.
  • Coordinating client care by liaising with medical providers, community support programs and other health care professionals.
  • Effectively manages client and family expectations regarding agency services, outcomes/discharge goals and ability to achieve independence in care.
  • Regularly evaluates home health client’s progress, in collaboration with team members; performs ongoing appropriate OASIS assessments and revises POC accordingly.
  • Clearly and concisely documents all contacts and follow up with clients, physicians, therapists, social workers or other persons directly involved in care of the client on coordination of care note.
  • Provides ongoing education to paraprofessional staff regarding current standards of practice, quality of care, infection control, safety, etc. in order to ensure clients receive appropriate, effective, quality care.
  • Perform yearly evaluations of paraprofessional staff assigned to clients of team.
  • Identifies home health client’s discharge planning needs when developing the plan of care and identifies and implements community referrals prior to client discharge and determines client’s readiness for discharge based on expected outcomes, goals and coverage guidelines.
  • Meets agency productivity requirements.
  • Participates in personal, professional growth and development. Attends all mandatory in-services and maintains current licensure.
  • Participates in on-call duties as defined by the on-call policy.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education, experience and skills required:

  • Registered Nurse with current license to practice professional nursing in the state.
  • Graduate of an accredited school of nursing program. Bachelor’s degree preferred.
  • Minimum of two years’ of nursing experience with demonstrated assessment, supervisory and organizational skills. at least one in the area of public health or home care is preferred.
  • Current valid driver’s license, dependable/available transportation and proof of current auto liability insurance.
  • Current CPR certification
  • Able to travel to each client’s home able to meet the needs of a client’s schedule. Able to work every other to every third weekend.
  • Attention to detail, ability to plan and meet deadlines, and flexibility to quickly adapt required.
  • An unmatched degree of integrity, with highly developed skills in fostering synergy, enthusiasm, optimism and energy in the workplace. Firm and decisive about meeting policies, procedures, deadlines and goals a necessity.
  • Strong verbal and interpersonal skills. Ability to work cooperatively within company as a team player. Positive, can-do attitude. Ability to work collaboratively with colleagues in an effective, harmonious, respectful manner.
  • Exceptional written communication skill that pays special attention to accuracy in documents.
  • Discretion and ability to keep confidences when working with ANS administration and staff members, key stakeholders, vendors and referral sources.

Language Skills: The RN Case Manager needs to have exceptional interpersonal and verbal communication skills, including the abilities to elicit information, actively listen, dialog freely, verbalize ideas effectively and provide solutions. This position also requires the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.  Ability to write reports, business correspondence, and procedure manuals.  Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required sit; stand; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl and talk or hear.  The employee is frequently required to walk. The employee must occasionally lift and or/move up to 50 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Mathematical Skills: Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Reasoning Ability: Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Office Technology: Ability to utilize equipment, office software (i.e. Word, Excel, PowerPoint) and web based applications to meet the needs of staff, co‐workers and ANS. Ability to utilize office equipment to prepare correspondence, reports, forms, mailings etc.


  • Adaptability: Flexible style; receptive to change. Process the ability to change (or be changed) to fit circumstances. Adjust with ease.
  • Approachability: Puts others at ease by listening, allowing adequate time for interactions, and giving undivided attention. Shows receptivity to message being delivered.
  • Composure: Responds to Information and situations in a self-controlled manner. Maintains a calm compose manner during stressful times.
  • Customer Focus: Builds effective relationships, identifies customer expectations, sees issues from their point of view: offers practical recommendations.
  • Ethics and Integrity: Possesses strong set of core values and beliefs consistent with social, ethical and organizational principals. Confronts unethical situations.
  • Listening: Gives attention to speaker, demonstrates non-verbal cues showing interest, and responds with information or questions, as appropriate.
  • Personal Accountability: Accepts responsibility for own actions, including failure. Embraces experiences as learning opportunities and not chances to blame.
  • Technical Skills: Demonstrates the knowledge and abilities necessary to perform required job elements to establish standards. Remains current regarding developments and trends in areas of expertise.
  • Time Management: Allocates time efficiently to the most important issues and knows what not to spend time on; completes work in a timely fashion.
  • Trust & Respect: Offers respect to all in the work environment adheres to high personal standards of acceptance, reliability, openness, and consistency of action with words.
  • Work Environment: 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.

How to Apply:

Photo of a Registered Nurse and woman in wheel chairOption 1: Download ANS Application  
Please be sure to fax this application to
414-481-9808 or drop it off  in person
at our Milwaukee or Racine location.

Option 2: Find us on Indeed

Option 3: Email us your cover letter and resume to contact@anshomecare.com



ANS is an Equal Employment Opportunity (EEO) Employer.