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

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 70,000 - 85,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Registered Nurse to provide CAP assessments, education, and care coordination in collaboration with an interdisciplinary team. The role includes transition planning and ensuring appropriate supports to reduce readmissions.

The RN will maintain CAP caseloads, develop person-centered plans, and document care activities in EPIC and e-CAP, contributing to performance improvement initiatives within Cape Fear Valley Health System.

Qualifications

• RN license in NC or compact state.
• 2 years’ acute care experience.
• 1 year in case management or care coordination.
• CM certification preferred.

Responsibilities

• Perform CAP beneficiary nursing assessments and education.
• Provide case management and care coordination for caseload.
• Coordinate transitions to/from acute care, LTAC, rehab, SNF, home care.
• Develop and monitor care plans with beneficiaries and teams.
• Document in e-CAP and EPIC; participate in QA activities.

Skills

Nursing assessment

Case management

Interdisciplinary collaboration

Communication

Problem solving

Critical thinking

Education

Associate degree in nursing

Bachelor’s degree in nursing preferred

Tools

EPIC

e-CAP

Job description

FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentCommunity Alternatives Program ServicesJob FamilyNursingWork ShiftDays (United States of America)SummaryRegistered 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.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Performs nursing assessments for CAP beneficiaries initially, at annual review, and when changes in status have occurredProvides case management and care coordination activities to assigned caseload in a manner that maximizes patient satisfaction, provider satisfaction and client centered outcomesCoordinates 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 avoidedFormulates 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 needsPerforms individual and interdisciplinary team monitoring of services provided and services required on a monthly to quarterly basisProvides follow-up visits and/or other support to beneficiaries who have been discharged from acute care or SNF to reduce the possibility of readmissionCompletes documentation via e-CAP and EPIC record management in a timely mannerParticipates in performance improvement activitiesDevelop resources to serve the assigned population through grants, networking with outside agencies and other departments within the Health SystemOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Associate’s degree in nursing requiredBachelor’s degree in nursing preferredCurrent Registered Nurse in North Carolina or Compact state licensure requiredProfessional Certification in Case Management preferredWork Experience:2 years’ experience in Acute Care or other Healthcare setting required1 year experience in case management, disease management or care coordination requiredHome Health experience preferredKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languagePositive interpersonal skillsExcellent communication, problem solving and negotiation skillsStrong organizational skillsCritical thinking skillsAbility to appropriately prioritize direct case management, beneficiary/family support and other dutiesKnowledge of Erickson’s developmental model and can demonstrate age specific interventionsKnowledgeable of and sensitive to the psychosocial, spiritual, and cultural needs of individualsArticulate orally and in written communication and can make accommodations for literacy and comprehension levelsStrong computer skills required for web-based documentationPhysical Requirements:Ability to make home visits or otherwise carry out duties away from the officeAccess to work related cell phone use as supported by Cape Fear Valley Health policyMust have visual acuity to see and read medical record documents, computer screens and computer printoutsSpeech and auditory abilities are required to allow for effective communicationAbility to ambulate, climb stairs and push or pull wheelchair patients at timesAbility to lift, load/unload beneficiary care supplies/equipment up to 35 poundsPosition may involve contact with blood or other potentially infectious materialRequired Licenses and CertificationsCCM - Commission For Case Manager CertificationCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity