Nurse Case Manager - Registered Nurse

Your Health Organization•Aiken, SC

1d•Hybrid

About The Position

We are seeking a Registered Nurse to service patients throughout the Aiken area. The Nurse Case Manager position is a critical part of the patient's care team, requiring the nurse to visit patients and facilitate with appropriate providers. This role involves daily travel to patients' homes, long-term care facilities, etc., to evaluate patients and initiate telemedicine visits, while providing quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice. The position is full-time, salary-based, working 8-hour shifts Monday-Friday (8am-5pm) in designated service areas including Aiken, Beech Island, Wagener, Allendale, Fairfax, and Salley. The company is a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. They offer comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs, and are committed to excellence and innovation, collaborating closely with facilities and families to ensure accessible, coordinated, and compassionate care.

Requirements

Must be a licensed nurse.
Registered nurse.
License must be in good standing with appropriate board/issuer.
Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
Strong written and verbal skills.
Basic computer knowledge.
Ability to manage and demonstrate effective leadership skills.
Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
Ability to foster a cooperative work environment.
Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
Must be able to work flexible hours and travel between offices, facilities, etc.
Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.

Nice To Haves

A minimum of three (3) years clinical experience.
Experience in community settings.

Responsibilities

Facilitate receiving all medical records from the patient's primary provider and specialists.
Review medical records.
Complete consents with patients.
Enroll patients in Care Management, if they meet eligibility criteria.
Initiate a Care Management Plan of Care, if the patient is eligible.
Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
Complete AWV's to be reviewed by the provider.
Complete cognitive impairment screenings.
Complete Social Determinants of Health (SDoH) assessments and/or screenings.
Complete ACP's to be reviewed with the patient by the provider.
Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
Evaluate for RPM devices, resources, or tools that may improve the patient's quality of life.
Communicate and coordinate care.
Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
Provide post-discharge education.
Evaluate for adaptive equipment and DME.
Evaluate for safe environment.
Evaluation of acute condition(s) or follow-up from previous visit.
Appropriately and accurately document and log Care Management activities.
Work in conjunction with care team to keep the patients Care Management care plans up to date.