Registered Nurse (RN) Case Manager | Care Transitions

Avera-Healt; Sioux Falls (SD); Remote; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO from day 1

5% retirement match for eligible staff

Career development and mentorship

Job summary

Avera at Home in Sioux Falls is seeking a Registered Nurse to manage the care of patients in the Care Transitions program. You will perform assessments, develop patient-centered plans, and coordinate follow-up visits and referrals to ensure effective discharge and ongoing care.

The role requires promoting education, coordinating with community resources, and maintaining thorough documentation in the EMR. Flexible schedules and team collaboration support optimal patient outcomes.

Qualifications

• Must be a Registered Nurse with an active license in state of practice.
• Experience in care transitions, home health, or hospice is preferred.
• Ability to assess, plan, and coordinate patient care including follow-up.

Responsibilities

• Manage care for patients in the Care Transitions program.
• Perform patient assessments and develop individualized care plans.
• Provide education and referrals to resources and services.
• Conduct follow-up calls and home visits as part of discharge planning.
• Coordinate with home care agencies and other services as identified.

Skills

Care coordination

Assessment

Patient education

Care planning

Education

RN license

Tools

EMR system

Job description

Location:Avera at Home Sioux FallsWorker Type:RegularWork Shift:Primarily days with rotating weekends and holidays (United States of America)Pay Range:The pay range for this position is listed below. Actual pay rate dependent upon experience.$31.00 - $46.25Position HighlightsMust live within 1.5 hours of an Avera facility.You Belong at AveraBe 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 OverviewManages 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 doImplements 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 QualificationsThe 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 HirePreferred Education, License/Certification, or Work Experience:Previous home health or hospiceExpectations and StandardsCommitment 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 SomeAvera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.PTO available day 1 for eligible hires.Up to 5% employer matching contribution for retirementCareer development guided by hands-on training and mentorshipAvera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail].