Company Info
SSM Health at Home

2802 Walton Commons Lane
Madison, WI, United States

Phone: 6082416938
Web Site:

Company Profile

Community Health & Wellness RN


Job ID:



Madison, WI, United States 




commensurate with experience per hour

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Employment Type:

Full time



Job Description:

Shift: M-F, 8:00am to 4:30pm or 8:30am to 5:00pm, on call potential for weekends and holidays
Location: 4639 Hammersley Road, Madison, WI 53711

The purpose of this position is to perform in various skilled nursing capacities to support community health and wellness programs.

Job Responsibilities:
This listing is not to be construed as all-inclusive. Other duties may be required and assigned.

Home Connection Visits
• Travels to patient residences to conduct health coaching visits following patient discharge from hospital.
• Evaluates patients’ current condition as it relates to his/her chronic disease.  Takes vital signs including pulse, respiratory, temperature and blood pressure.
• Performs medication reconciliation.  Assists patients to improve medication understanding and adherence.
• Provides education to the patient on his/her chronic disease.  Ascertains the patient’s understanding of his/her care plan and the physician’s instructions at home visit and during follow up phone calls.  Provides guidance and support to the patient efforts in adopting healthy behaviors.
• Advises patient of the recommended need for physician intervention.  Encourages the patient to attend post-hospitalization physician visits.

Foot Care
• Assesses skin and feet for sign and symptoms of infection or potential infection and encourages follow-up with physician.  Provides proper diabetic foot care education as appropriate.  Perform appropriate post clinic follow-up as directed by Manager
• Performs basic foot and nail care including cleaning of feet, cutting of nails and providing a brief massage of the feet at foot care clinics and in client’s homes.
• Recognizes the signs and symptoms of infection and accurately relays information to client and management staff.
• Provides basic foot care education and guidance to clients.
• Collects, tallies, and reconciles money collected at the foot clinic sites.  Responsible for the prompt and safe transportation of money collected to office.
• Guides and instructs volunteers at the foot clinics.
• Advises supervisor of any requests for changes in services or discontinuation of services. 
• Cleans and organizes area after performing services.

Nurse Consulting
• Performs medication review and reconciliation.  Obtains and verifies a list of each resident’s medications and compares with medicines ordered to identify and resolve any discrepancies with prescriber.
• Completes physical assessments for residents.  Provides intramuscular and subcutaneous injections to residents as requested for Home Health standing orders.
• Performs a chart review and audit.
• Reports and documents physical assessments, medication reconciliations and chart reviews.
• Communicates corrective attention to facility staff and managers based on assessments and reviews.
• Monitors, evaluates and recommends corrective actions on health and safety concerns for residents.
• Ensures State of Wisconsin rules and regulations are followed for a Community Based Residential Facility.
• Serves as an independent health advocate for residents to ensure a safe and health living environment.

• Completes accurate and timely documentation of visits.  Completes and submits timesheets in a timely manner. 
• Attends mandatory orientations, trainings, in-services and meetings.
• Performs TB testing.
• Performs Hep B, TB and flu immunizations.

Job Requirements:

Associate’s Degree in Nursing with two years nursing experience preferably in cardiac, acute care, or care management or any combination of education and experience that provides equivalent knowledge, skills or abilities.  One year prior community health and home health nursing desired.

Current State of Wisconsin RN licensure required. Bachelor’s Degree in Nursing preferred.

This position requires travel to patient homes, referral sources, foot clinics and office locations.

Must maintain a valid Wisconsin driver’s license.
Must maintain an acceptable driver’s record per company policy.
Must maintain proof of current auto insurance.
Must have access to a vehicle in good working condition.
Ability to occasionally work weekends.