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

Facility

Cape Fear Valley Medical Center

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 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