RN Care Manager - Community - Days

Sanford Health•Sioux Falls, SD

1d•$32 - $48

About The Position

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. 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 and may manage the disease registries by identifying and following up with patients not meeting clinical and evidenced-based goals as well as Sanford approved clinical guidelines. Provides services that focus on health and wellness. 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.

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.
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).
Minimum of two years’ clinical experience preferred.
Currently holds an unencumbered 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.

Responsibilities

Utilizing the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care.
Collecting and relaying information (assessment, screening, diagnostic testing results and risk stratification) to providers on both hospital and clinic patients enrolled in the approved programs.
Managing patients in the community.
Making 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.
Developing and providing individualized patient education based on assessed needs.
Developing and implementing individualized care plan.
Assisting with the coordination of patient care across the continuum by collaborating with the inter-professional team and community partners.
Working with the clinical team and may manage the disease registries by identifying and following up with patients not meeting clinical and evidenced-based goals as well as Sanford approved clinical guidelines.
Providing services that focus on health and wellness.
Providing healthcare leadership, coordination of services, and the implementation of evidence-based practice to support the overall goals of the designated setting and/or program.
Applying population health care management strategies to panels of patients.
Demonstrating 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.
Functioning within the scopes and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure.