Registered Nurse; RN) Case Manager | Family Med Clinic

Pay Range

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$27.75 - $41.25

Avera Sacred Heart Pavilion

Regular

Day Shift (United States of America)

Hours: Monday
- Friday, Days

Student Loan Repayment: This position may be eligible for Avera’s Student Loan Repayment Program, which helps you pay off your loans and save money. Each month an extra payment of $167 (up to $10,000) from Avera will help pay down your principal balance faster.

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.

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.

• 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.

The individual must be able to work the hours…