RN Care Manager - Community - Days

Sanford Health•Sioux Falls, SD

5d•Hybrid

About The Position

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. The Comprehensive Care and Community Services team consists of RN care manager, CNP, LCSW, and Community Health Worker roles. The team makes home visits to medically and socially complex patients by referral from Sanford Medical Center, Sanford clinics and Good Samaritan Society facilities. Goals include reducing readmissions, ED visits, barriers to healthcare related to social drivers of health, and supporting patient engagement with a primary care team. Scheduled days are typically Mon-Fri between 0800-1700, depending on needs of patients served. The RN Care Manager Ambulatory works with an interdisciplinary team to manage patients in the community. The team makes home visits and sees patients in various locations in the community to achieve the goal of reducing readmissions, removing barriers associated with social drivers of health, and transitioning complex patients from hospital or nursing facility to home. The team includes other RN CMs, CNPs, LCSW-PIP, and Community Health Worker roles. This role requires an autonomous, self-directed professional RN with nursing experience in Inpatient, ambulatory, community, or nursing facility settings. Responsible for utilizing the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care. Collects and relays information (assessment, screening, diagnostic testing results and risk stratification) to providers on both hospital and clinic patients enrolled in the approved programs.

Requirements

Bachelor's degree in Nursing strongly preferred in Bemidji and Rapid City. Required in Fargo and Sioux Falls (Sanford USD Medical Center and Clinics). Required in Bismarck or enrolled and starting a Bachelor’s degree program within one year of hire with a completion date within three years upon date of hire into position. Required in Fargo Network and Sioux Falls Network, or employees hired after January, 2025, who do not possess a Bachelor’s degree in the required field, leadership may consider an educational plan with proven continuous action toward achieving a Bachelor’s degree in Nursing within five years of hire into position. Approval from the Nursing Executive for the market is required in order to waive the bachelor degree requirement (at time of hire). Additionally, for Rural Health Network facilities, for current employees, leadership may have considered acceptable qualifications and work experience equivalency based on facility size, rural market, and business need, prior to new Sanford education requirements.
Graduate from an accredited nursing program, including, but not limited to, those accredited by the Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), or National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Currently holds an unencnuered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state.
Obtains and subsequently maintains required department specific competencies and certifications.
Basic Life Support (BLS) is required and must be obtained within six months of employment.
Must possess a valid driver’s license.

Nice To Haves

Minimum of two years’ clinical experience preferred.

Responsibilities

Develops and provides individualized patient education based on assessed needs.
Develops and implements individualized care plan.
Assists with the coordination of patient care across the continuum by collaborating with the inter-professional team and community partners.
Works with the clinical team to support patient transition from hospital to home and to reduce patient readmissions, remove barriers to social drivers of health, and support complex medical and social situations.
Provides healthcare leadership, coordination of services, and the implementation of evidence-based practice to support the overall goals of the designated setting and/or program.
Applies population health care management strategies to panels of patients.
Demonstrates competency and practices within the full scope of nursing expertise/knowledge and utilizes appropriate age and population specific standards as designated in their assigned clinical setting.
Functions within the scopes and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure.
The Sanford Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.
The RN Care Manager Ambulatory works with an interdisciplinary team to manage patients in the community.
The team makes home visits and sees patients in various locations in the community to achieve the goal of reducing readmissions, removing barriers associated with social drivers of health, and transitioning complex patients from hospital or nursing facility to home.
The team includes other RN CMs, CNPs, LCSW-PIP, and Community Health Worker roles.
This role requires an autonomous, self-directed professional RN with Inpatient and ambulatory, community, or nursing facility experience.