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

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
• Other duties as assigned

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

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