Registered Nurse (Care Center) - Full Time

SSM Health; Fond du Lac (WI); On-site; USD 65,000 - 90,000; Full time

Job summary

SSM Health in Wisconsin seeks a dedicated Long Term Care professional to support patient transitions from hospital to long-term care, handle admissions documentation, and contribute to infection prevention efforts. The role collaborates with case managers, physicians and nursing home staff to assess needs, coordinate orders, and ensure timely transfer planning while maintaining high quality patient care.

Full-time, Monday–Friday day shift; background in nursing or licensed education equivalent

Qualifications

• Graduate of accredited school of nursing or education equivalency for licensing.
• Ability to assess resident care needs and plan multidisciplinary care.
• Strong documentation and communication with hospital staff and care teams.

Responsibilities

• Reviews and analyzes resident referrals to determine the appropriateness of long-term care and infusion services.
• Coordinates all aspects of service to optimize the resident’s smooth transition from hospital to long term care.
• Communicates key components of resident’s needs and physicians’ orders to clinicians to help establish the resident’s plan of care.
• Assesses resident care needs by gleaning hospital records and/or referral information to determine suitability of referral.
• Plans for resident care by ensuring pending referrals information is passed on to nursing supervisors and rehab services.
• Seeks appropriate orders in planning multidisciplinary care and reassesses progress to identify intervention needs.

Education

Graduate of accredited school of nursing or education equivalency for licensing

Job description

Join a team where your work matters—every moment, every patient, every community. At SSM Health, you‘ll be empowered to grow, supported to thrive, and inspired to make a lasting impact.

The role will help to ensure a smooth transition for rehab residents (admissions orders, documentation, assessments, etc) and will handle additional functions such as infection prevention.

Department

Long Term Care

Schedule

Full time M-F

Reviews and analyzes resident referrals to determine the appropriateness of long-term care and infusion services. Coordinates all aspects of service to optimize the resident’s smooth transition from hospital to long term care. Communicates key components of resident’s needs and physicians‘ orders to clinicians to help establish the resident’s plan of care. Provides educational information to case managers, physicians, key hospital staff, and nursing home staff regarding qualifying criteria, access to services, etc.

Assesses resident care needs by gleaning hospital records and/or referral provided information for information necessary to determine the appropriateness of referral and to initiate resident records.Identifies educational needs for residents/significant others.Plans for resident care by ensuring that information regarding pending referrals is passed on to nursing supervisors, clinical supervisor or rehab services, and others as necessary in a timely manner.Coordinates with nursing supervisors, clinical supervisor or rehab services, and others in initiating care.Seeks appropriate orders in planning multidisciplinary care.Completes evaluation of care by reassessing residents systematically to identify progress and trends that require intervention; this may include seeing the re-hospitalized resident and/or reviewing their record.Communicates with supervisor regarding the cases he/she is managing while awaiting the initiation of care.Assesses and discerns environmental factors which are hazardous and/or unsafe and responds according to policy and agency expectation.Graduate of accredited school of nursing or education equivalency for licensing

Frequent sitting, reaching and keyboard use/data entry. Work Shift:Day Shift (United States of America)

SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law.