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

capefearvalley; United States; On-site; USD 65,000 - 85,000; Full time

Job summary

Cape Fear Valley Health System seeks an experienced RN for the Community Alternatives Program Services in Fayetteville, NC. You will perform nursing assessments, educate CAP beneficiaries, and coordinate care with the interdisciplinary team and Health Benefits as outlined in policy.

The role emphasizes transition coordination to and from acute care, LTAC, rehab, SNF and home care, maintaining a caseload and providing whole-person care coordination. Documentation is via e-CAP and EPIC.

Qualifications

• Associate's degree in nursing is required.
• Bachelor's degree in nursing is preferred.
• Current RN licensure in North Carolina or a Compact state.

Responsibilities

• Performs nursing assessments for CAP beneficiaries and documents findings.
• Provides case management and care coordination to a caseload.
• Coordinates transitions to and from acute care and other settings.
• Formulates care plans with person-centered goals in collaboration with the team.
• Monitors services monthly to quarterly and supports follow-up after discharge.
• Completes documentation in e-CAP and EPIC in a timely manner.
• Participates in performance improvement activities.
• Develops resources through grants and interdepartmental networking.

Skills

English proficiency

Interpersonal skills

Communication

Organizational skills

Critical thinking

Education

Associate's degree in nursing

Bachelor's degree in nursing preferred

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

• 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

Minimum Qualifications

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 skillst??????
• 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 times
• Ability 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