Registered Nurse (RN) Case Manager - Care Transitions

Avera Health; Sioux Falls (SD); On-site; USD 43,000 - 63,000; Full time

Job summary

Avera Health in Sioux Falls is seeking a Registered Nurse to manage care transitions, including patient assessments, care planning, and home visits. You will work within a multidisciplinary team to ensure effective discharge planning and follow-up.

The role emphasizes coordinating care across facilities, educating patients and families, and ensuring timely access to services. Must live within 1.5 hours of an Avera facility and be able to perform in a fast-paced environment.

Qualifications

• Must be a Registered Nurse with an active license in the state of practice.
• Experience in home health or hospice is preferred.
• Ability to communicate effectively with patients, families, and team members.

Responsibilities

• Perform admission and follow-up calls using the nursing process and document in the EMR.
• Develop patient-centered care plans and coordinate care with home health agencies and community resources.
• Provide education and disease management information to patients and caregivers as directed by the physician.

Skills

Nursing assessment

Care coordination

Triage

Education

Registered Nurse license - active

Job description

Location:

Avera at Home Sioux Falls

Worker Type:

Regular

Work Shift:

Primarily days with rotating weekends and holidays (United States of America)

Pay Range:

$31.00 - $46.25

Position Highlights

Must live within 1.5 hours of an Avera facility.

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

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.

What you will do

• 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.

Essential Qualifications

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. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

Registered Nurse (RN) - Board of Nursing An active license in state of practice Upon Hire

Preferred Education, License/Certification, or Work Experience:

Previous home health or hospice

Expectations and Standards

Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.

Promote Avera's values of compassion, hospitality, and stewardship.

Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.

Maintain confidentiality.

Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.

Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportun