Registered Nurse (RN) Case Manager | Care Transitions

Avera•Sioux Falls, SD

2d•$31 - $46

About The Position

Manages the care of patients referred to the Care Transitions program. Performs patient assessment and develops a patient-centered plan of care including follow-up phone calls and home visits. Addresses clinical concerns, provides education, makes referrals to appropriate resources and services, assists with access to care, improves care coordination and assures an effective discharge plan for patients at the end of the Care Transitions service. Develops patient care plans in accordance with established protocols. Maintains contact with referring facilities, agencies, and community resources.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Registered Nurse (RN) - Board of Nursing
An active license in state of practice
Upon Hire

Nice To Haves

Previous home health or hospice

Responsibilities

Implements the nursing process utilizing proficient assessment skills in the performance of admission and follow-up phone calls including documentation within the electronic medical record.
Analyzes the assessment data and implements a plan of care individualized to the patient including expected outcomes, including efficient and effective utilization of resources to achieve positive outcomes.
Manages the plan of care according to the patient needs and disease protocols including coordination and referral to home care agencies for home visits.
Provides follow-up outbound phone call assessment and assures appropriate referrals between services upon discharge from the Care Transitions program.
Provides clinical management of patients calling in with symptoms and medical concerns, including appropriate triage.
Makes referrals and works collaboratively with referral sources and community services including follow-up medical care, hospital-based or out-patient services or community resources, including home care or hospice as identified in the plan of care.
Provides education and educational resources to patients referred to the Care Transitions program, including assuring patients have access to care including medications, supplies, home care services, follow-up appointments, mental health services and/or outpatient services.
Participates in quality improvement activities within the department and makes recommendations to ensure best practice based on clinical expertise.
Demonstrates ability to affect the behavior of others to follow the recommended alternatives to care which includes providing thorough instruction and disease management education to patients and/or caregivers as ordered by the physician.
Educates patients, families, and caregivers about disease process, community resource and recommended self-care.
Achieves and maintains a current knowledge base including existing and new disease management protocols, community resources availability, and documentation requirements.