Job Description
Facility: Sanford Education Campus
Address: 1410 W 25th St, Sioux Falls, SD 57105
Shift: 8 Hours - Day Shifts
Job Schedule: Full time, 8 Hours - Day Shifts
Weekly Hours: 40.00
Salary Range: $32.00 - $48.00
Department Details
The Comprehensive Care and Community Services team consists of RN care manager, CNP, LCSW, and Community Health Worker roles. The team makes home visits to medically and socially complex patients by referral from Sanford Medical Center, Sanford clinics and Good Samaritan Society facilities. Goals include reducing readmissions, ED visits, barriers to healthcare related to social drivers of health, and supporting patient engagement with a primary care team.
Scheduled days are typically Mon-Fri between 0800-1700, depending on needs of patients served.
Job Summary
The RN Care Manager Ambulatory works with an interdisciplinary team to manage patients in the community. The team makes home visits and sees patients in various locations in the community to achieve the goal of reducing readmissions, removing barriers associated with social drivers of health, and transitioning complex patients from hospital or nursing facility to home. The team includes other RN CMs, CNPs, LCSW-PIP, and Community Health Worker roles.
This role requires an autonomous, self-directed professional RN with nursing experience in Inpatient, ambulatory, community, or nursing facility settings.
Responsible for utilizing the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care. Collects and relays information (assessment, screening, diagnostic testing results and risk stratification) to providers on both hospital and clinic patients enrolled in the approved programs. Develops and provides individualized patient education based on assessed needs. Develops and implements individualized care plan. Assists with the coordination of patient care across the continuum by collaborating with the inter-professional team and community partners. Works with the clinical team to support patient transition from hospital to home and to reduce patient readmissions, remove barriers to social drivers of health, and support complex medical and social situations. Provides healthcare leadership, coordination of services, and the implementation of evidence-based practice to support the overall goals of the designated setting and/or program. Applies population health care management strategies to panels of patients.
Demonstrates competency and practices within the full scope of nursing expertise/knowledge and utilizes appropriate age and population specific standards as designated in their assigned clinical setting. Functions within the scopes and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The Sanford Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.
The RN Care Manager Ambulatory works with an interdisciplinary team to manage patients in the community. The team makes home visits and sees patients in various locations in the community to achieve the goal of reducing readmissions, removing barriers associated with social drivers of health, and transitioning complex patients from hospital or nursing facility to home. The team includes other RN CMs, CNPs, LCSW-PIP, and Community Health Worker roles.
This role requires an autonomous, self-directed professional RN with Inpatient and ambulatory, community, or nursing facility experience.