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The RN Care Manager, as part of an interdisciplinary team (IDT), serves frail elders, adults with physical disabilities and adults with intellectual/developmental disabilities who are members of Lakeland Care, Inc. (LCI). The team’s goal is to promote the overall well-being of the members LCI serves by providing high quality, person-centered, outcome-based care.

Under general direction of the Care Management Supervisor, this position provides care management and service coordination to LCI members. As a member of the IDT, the RN Care Manager (RNCM) arranges for provision of services and supports based on a comprehensive assessment of the member's identified outcomes and needs. The IDT staff monitors the provision of services based on the member-centered plan per LCI policy and procedures, and Department of Health Services (DHS) contract requirements.

Essential Competencies:

• As part of an interdisciplinary team (which also includes a care manager and the member and/or legal representative), the RNCM conducts a comprehensive assessment of the member's outcomes, needs and risks; and reassesses as the member’s outcomes and/or condition changes.
• Coordinate acute and primary care services, care transitions and related follow-up care.
• Develop, coordinate, monitor, and evaluate members’ outcome-based member-centered plans, considering cost and effectiveness in authorizing services and choosing providers.
• Promote prevention and wellness by incorporating preventative, supportive, restorative, and rehabilitative care into the care planning process.
• In collaboration with the Care Manager (CM), implement risk mitigation strategies to promote the member’s health, safety and independence while respecting the member’s rights.
• Participate in on-going training to maintain current knowledge to ensure compliance with Federal and State regulations, LCI policy and procedure and accepted professional standards.
• Create and maintain member records as required by the Department of Health Services (DHS) contract and LCI policy.
• Participate in, via face-to-face, in-home visits and care conferences involving the member, their supports, and providers to assess, reassess, and address health and medically related needs.
• Participate in the 24-hour on-call rotation as necessary.
• Participate in team meetings and internal workgroups as required/requested.
• Provide nursing care in accordance with the Nurse Practice Act.
• Maintain the confidentiality of member information and protected health information (PHI) as required by State and Federal regulations, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

• Current License to practice as a Registered Nurse in the State of Wisconsin.
• Bachelor’s degree in nursing strongly preferred.
• Two (2) or more years of skilled nursing experience preferred, ideally in gerontology/disabilities and/or home care.
• Ability to access members’ homes which are not required to comply with the ADA regulations.
• Ability to lift up to 25lbs.
• Current driver’s license, acceptable driving record and proof of adequate insurance.