Registered Nurse - Long-Term Care Transitions

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

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