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

Avera Internal Medicine Cliff Ave
Work Shift:
Day Shift (United States of America)
The pay range for this position is listed below. Coordinated Care Case Manager with Internal Medicine
Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. 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 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.
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.
Oversees the development, procurement and adoption of patient self-management educational resources used by the primary clinical teams.
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. 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

Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.
Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.
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. 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 View phone number on click.appcast.io or send an email to View email address on click.appcast.io.