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

Position: RN Transitions and Care Coordinator (Exempt), Community Alternative Program Services, Per-Diem Days
## RN Transitions and Care Coordinator (Exempt), Community Alternative Program Services, Per-Diem Days Apply:
CFV:
Part time:
Posted Yesterday:
40917
** 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…