Registered Nurse (RN) Case Manager | Care Transitions

Avera • Sioux Falls, SD

4d

About The Position

The Registered Nurse (RN) Case Manager manages care for patients referred to Avera’s Care Transitions program. The role includes assessing patients, developing individualized patient-centered care plans, making follow-up phone calls and home visits, addressing clinical concerns, and providing education and referrals to appropriate services and community resources. The nurse supports access to care, improves care coordination, and helps ensure effective discharge plans when patients leave the Care Transitions program.

The position maintains contact with referring facilities, agencies, and community resources; coordinates care in accordance with established protocols and disease-management needs; and provides clinical triage for patients who call with symptoms or medical concerns. It also involves documentation in the electronic medical record, referrals for follow-up and home-based services, and participation in departmental quality improvement.

The position is based at Avera at Home in Sioux Falls. Employees must live within 1.5 hours of an Avera facility. The shift is primarily days, with rotating weekends and holidays. The listed pay range is $31.00–$46.25 per hour, with the actual rate dependent on experience.

Requirements

• Active Registered Nurse (RN) license in the state of practice upon hire.
• Ability to work the specified hours.
• Ability to perform essential job functions satisfactorily, including adequate visual acuity and effective communication, hearing, and speech-discrimination abilities.
• Ability to maintain confidentiality and work effectively in a team environment.
• Ability to comply with applicable safety principles, laws, regulations, and standards.

Nice To Haves

• Previous home health or hospice experience.

Responsibilities

• Use the nursing process and assessment skills for admission and follow-up phone calls, documenting care in the electronic medical record.
• Analyze assessment data and develop an individualized plan of care with expected outcomes and efficient use of resources.
• Manage care according to patient needs and disease protocols, including coordinating referrals to home care agencies for home visits.
• Conduct follow-up outbound calls, assess patients, and ensure appropriate referrals between services when patients leave the Care Transitions program.
• Provide clinical management and appropriate triage for patients calling with symptoms or medical concerns.
• Coordinate with referral sources and community services for follow-up medical care, hospital-based or outpatient services, home care, hospice, and other resources identified in the care plan.
• Educate patients and provide educational resources, supporting access to medications, supplies, home care, follow-up appointments, mental health services, and outpatient services.
• Participate in departmental quality improvement activities and recommend best practices based on clinical expertise.
• Encourage patients and caregivers to follow recommended care alternatives through thorough instruction and disease-management education as ordered by a physician.
• Educate patients, families, and caregivers about disease processes, community resources, and recommended self-care.
• Maintain current knowledge of disease-management protocols, community resource availability, and documentation requirements.
• Maintain contact with referring facilities, agencies, and community resources.

Benefits

• PTO available from day one for eligible hires.
• Up to 5% employer matching contribution for retirement.
• Career development through hands-on training and mentorship.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed