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

Cape Fear Valley Health System; United States; On-site; USD 68,000 - 95,000; Full time

Job summary

Cape Fear Valley Health System in Fayetteville, NC seeks a Registered Nurse to support Community Alternatives Program Services. You will perform nursing assessments, provide education, and coordinate care in collaboration with an interdisciplinary team.

Responsibilities include case management, transitioning beneficiaries between care settings, and ensuring timely documentation in e-CAP and EPIC. NC RN licensure and CCM certification preferred; 2+ years in acute care or care coordination are

Qualifications

• Associate degree in nursing required; bachelor's preferred.
• NC or compact state RN licensure required.
• CCM certification preferred.
• 2 years acute care or healthcare setting experience required; 1 year in case management/care coordination.

Responsibilities

• Perform nursing assessments for CAP beneficiaries at intake and during status changes.
• Provide case management and care coordination to assigned caseload.
• Coordinate Money Follows the Person and Community Transitions to reduce LOS and readmissions.
• Develop care plans with beneficiaries and support persons with person-centered goals.
• Monitor services monthly to quarterly and ensure timely documentation.
• Conduct follow-up visits to reduce readmissions after discharge.
• Document in e-CAP and EPIC; support performance improvement.
• Develop resources for the population via grants and interdepartmental collaboration.
• Perform other duties as assigned.

Skills

Care coordination

Communication

Critical thinking

Organizational skills

Problem solving

Education

Associate’s degree in nursing

Bachelor’s degree in nursing

Tools

EPIC

e-CAP

Job description

Facility: Cape Fear Valley Medical Center

Location: Fayetteville, North Carolina

Department: Community Alternatives Program Services

Job Family: Nursing

Work Shift: Days (United States of America)

Summary

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.

Major Job Functions

The 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 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

Minimum Qualifications

The 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 required Bachelor’s degree in nursing preferred

Current Registered Nurse in North Carolina or Compact state licensure required

Professional Certification in Case Management preferred

Work Experience: 2 years’ experience in Acute Care or other Healthcare setting required 1 year experience in case management, disease management or care coordination required Home Health experience preferred

Knowledge, Skills, and Abilities 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

Physical Requirements

• 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 timesAbility to lift, load/unload beneficiary care supplies/equipment up to 35 pounds
• Position may involve contact with blood or other potentially infectious material

Required Licenses and Certifications

• CCM - Commission For Case Manager Certification

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity

For exceptional healthcare come to Cape Fear Valley Health where caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process. At Cape Fear Valley Health, our goal is to improve the quality of every life we touch. Our diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time.

Cape Fear Valley is a 950-bed, 8-hospital regional health system, the 8th largest in North Carolina, with more than 1 million inpatient and outpatients annually. A private not-for-profit organization with over 7,000 employees and 850 physicians. Our employees and physicians proudly serve a seven-county region of southeastern North Carolina, including Fayetteville, Fort Bragg, Hope Mills, Raeford, Lumberton, Elizabethtown, Clinton, Lillington, Dunn and beyond. Our medical facilities include Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Cape Fear Valley Rehabilitation Center, Behavioral Health Care, Bladen County Hospital, Hoke Hospital, Central Harnett Hospital, Betsy Johnson Hospital, as well as more than 60 medical offices and specialty care clinics spread throughout the Cape Fear region.