Continuous Care Nurse - 115K

Your Health Organization; Rock Hill (SC); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Competitive Compensation Package with

Employer Matched 401K

Free Visit & Prescriptive Services

Employer Matched HSA

Generous PTO Package

Vehicle allowance

Job summary

Your Health in Rock Hill, SC seeks a Registered Nurse to join our growing primary care team as a Continuous Care Nurse/Nurse Case Manager. This full-time in-home role covers the Rock Hill area, with a 7-on/7-off, 12-hour shift schedule and daily travel between homes and facilities.

You will collaborate with an interdisciplinary team to stabilize symptoms, coordinate care, and ensure patient comfort and safety.

Qualifications

• Licensed RN in good standing
• Minimum 3 years clinical experience preferred
• Experience in community/home health settings preferred
• Proven ability to communicate and collaborate with care teams, patients, and caregivers
• Strong written and verbal skills; basic computer proficiency

Responsibilities

• Facilitate receiving Medical records from patients’ providers and specialists
• Review medical records and complete consents
• Enroll patients in Care Management if eligible
• Initiate Care Management Plan of Care when eligible
• Capture diagnoses with highest specificity and close documentation gaps
• Complete AWVs and cognitive impairment screenings
• Perform SDoH assessments and ACPs with providers
• Evaluate for home health, hospice, or RPM opportunities
• Coordinate care and reconcile medications across settings
• Document Care Management activities and maintain up-to-date care plans

Skills

RN license

Care coordination

Interdisciplinary teamwork

Communication

Travel readiness

Education

Registered Nurse (RN) license

Tools

EMR systems

Job description

We are seeking a Continuous Care Nurse to service our patients throughout the Rock Hill area. The role of the Continuous Care Nurse er position is a critical part of the patient’s care team, to provide in-home intensive, short-term, bedside clinical care to manage uncontrolled symptoms. The Continuous Care Hospice Nurse collaborates closely with the interdisciplinary hospice team to stabilize symptoms and ensure comfort, dignity, and safety. Provide quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice.

The Nurse Case Manager will have a full patient load against all patients in the region based upon priority

Nurse Case Manager's perform care in homes in their designated service area. You must have reliable transportation as travel is required daily. This is a full time, salary-based working position

- Track Schedule 7 on 7 off 12/hr shifts

The following service area(s) are currently available:

Rock Hill area

About

We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. Committed to excellence and innovation, our team collaborates closely with facilities and families to ensure accessible, coordinated, and compassionate care.

Why Choose a Career at Your Health?

Providing high quality care for our patients is the center of what we do, and we provide the same care for our employees. Here are some of the benefits that are available to our employees.

• Competitive Compensation Package with Bonus Opportunities
• Employer Matched 401K
• Free Visit & Prescriptive Services with HDHP Insurance Plan
• Employer Matched HSA
• Generous PTO Package
• Vehicle allowance

What Are We Looking For?

Your Health is currently looking for a Registered Nurse to join our growing primary care family. A successful Nurse Case Manager will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

The following is a list of essential functions, which may be subject to change at any time and without
notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).

Area of Responsibility:

• Facilitate receiving all medical records from the patient’s primary provider and specialists.
• Review medical records.
• Complete consents with patients.
• Enroll patients in Care Management, if they meet eligibility criteria.
• Initiate a Care Management Plan of Care, if the patient is eligible.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete AWV’s to be reviewed by the provider.
• Complete cognitive impairment screenings.
• Complete Social Determinants of Health (SDoH) assessments and/or screenings.
• Complete ACP’s to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
• Evaluate for adaptive equipment and DME.
• Evaluate for safe environment.
• Evaluation of acute condition(s) or follow-up from previous visit.
• Appropriately and accurately document and log Care Management activities. Work in conjunction with care team to keep the patients Care Management care plans up to date.

Qualifications:

• Must be a licensed nurse. Registered nurse preferred. License must be in good standing with appropriate board/issuer.
• A minimum of three (3) years clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal skills.
• Basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills.
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
• Ability to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order