Registered Nurse (RN) Case Manager | Internal Medicine Coordinated Care

Location: Avera Internal Medicine Cliff Ave Worker Type: Regular Work Shift: Day Shift (United States of America) Pay Range: The pay range for this position is listed below. Actual pay rate dependent upon experience. $27.75 - $41.25 Position Highlights Coordinated Care Case Manager with Internal Medicine Primarily Located at Plaza 2 You Belong at Avera Be 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 Overview Accountable for supporting patient care navigation in the clinic setting. The RN's primary responsibility is to manage care for the patients of the primary care practice to promote effective education, self-management support, and timely health care delivery. This will include developing and monitoring care management processes and support primary clinical teams with these efforts. It will also include identifying the high acuity patient population and working to ensure care coordination for this patient population. The position involves some patient triage. The RN will work with the clinic leadership and medical director (lead physician) of the practice to develop this position to best serve the needs of the patient panel and the primary care teams. This individual will work closely with the leadership of Care Coordination/Medical Home and others to support the development, maintenance, and reporting of quality measures within the medical home model. What you will do Works with all clinical teams as a resource on care management of all patients of the practice, including educating the patient about self-management tasks they can undertake to gain greater control of their health status, and, manage patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner. Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management, and provides leadership for patient care teams. Works with social services and nursing to identify, plan for, and provide an appropriate follow-up plan of care for patients. Communicates this plan of care to patient’s families, medical providers, hospital staff when appropriate, community support, other agencies and departments. Provides follow-up contact with patient as indicated to ensure compliance with recommendations – medications, lab/x-ray, specialists visits, PCP visits, dieticians, CDE, etc. Reviews monthly status reports, dashboard results, and other information related to clinical care delivery. Communicates with physician groups’ regarding statistical and financial impact of care delivery. Serves as a resource for clinic care team education on changing payor requirements. Collaborates with payer Case Managers for additional services when appropriate. Participates in regular team meetings and peer review activities. Anticipates the needs of this patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit. Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments. Determines and completes appropriate referrals. Oversees the development, procurement and adoption of patient self-management educational resources used by the primary clinical teams. Essential Qualifications The 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 the state of practice Upon Hire Preferred Education, License/Certification, or Work Experience: 1-3 years of Clinic Nursing experience 4-6 years Case Management and /or homecare experience Expectations and Standards Commitment 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 Some Avera 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 retirement Career development guided by hands-on training and mentorship Avera 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 talent@avera.org .