RN Transitions and Care Coordinator (Exempt), Community Alternative Program Services, Per-Diem Days

Cape Fear Valley Health

1d•Hybrid

About The Position

Registered Nurse, RN performs nursing assessments, provides education and other nursing interventions for CAP beneficiaries as indicated in collaboration with the interdisciplinary team and the Department of Health Benefits. Provides transition coordination for CAP beneficiaries to and from the acute care, LTAC, rehabilitation, SNF and home care settings. Maintains a caseload of CAP beneficiaries and provides whole person interdisciplinary care coordination, and CAP case management as specified by the Department of Health Benefits in Clinical Policy for the Community Alternatives Programs.

Requirements

Associate’s degree in nursing required
Current Registered Nurse in North Carolina or Compact state licensure required
2 years’ experience in Acute Care or other Healthcare setting required
1 year experience in case management, disease management or care coordination required
Proficiency in reading, writing, and speaking the English language
Positive interpersonal skills
Excellent communication, problem solving and negotiation skills
Strong organizational skills
Critical thinking skills
Ability to appropriately prioritize direct case management, beneficiary/family support and other duties
Knowledge of Erickson’s developmental model and can demonstrate age specific interventions
Knowledgeable of and sensitive to the psychosocial, spiritual, and cultural needs of individuals
Articulate orally and in written communication and can make accommodations for literacy and comprehension levels
Strong computer skills required for web-based documentation
Ability to make home visits or otherwise carry out duties away from the office
Access to work related cell phone use as supported by Cape Fear Valley Health policy
Must have visual acuity to see and read medical record documents, computer screens and computer printouts
Speech and auditory abilities are required to allow for effective communication
Ability to ambulate, climb stairs and push or pull wheelchair patients at times
Ability to lift, load/unload beneficiary care supplies/equipment up to 35 pounds
Position may involve contact with blood or other potentially infectious material
CCM - Commission For Case Manager Certification

Nice To Haves

Bachelor’s degree in nursing preferred
Professional Certification in Case Management preferred

Responsibilities

Performs nursing assessments for CAP beneficiaries initially, at annual review, and when changes in status have occurred
Provides case management and care coordination activities to assigned caseload in a manner that maximizes patient satisfaction, provider satisfaction and client centered outcomes
Coordinates Money Follows the Person Transitions as well as Community Transitions such that the length of stay in acute care, or other qualifying level of care is reduced, appropriate supports are put in place, and readmissions are avoided
Formulates the plan of care in collaboration with the beneficiary and support persons with the service plan specifying person-centered goals, objectives, and formal as well as informal support services to address identified medical and functional care needs
Performs individual and interdisciplinary team monitoring of services provided and services required on a monthly to quarterly basis
Provides follow-up visits and/or other support to beneficiaries who have been discharged from acute care or SNF to reduce the possibility of readmission
Completes documentation via e-CAP and EPIC record management in a timely manner
Participates in performance improvement activities
Develop resources to serve the assigned population through grants, networking with outside agencies and other departments within the Health System
Other duties as assigned