Registered Nurse; RN-Continuum of Care Mgr Peds

Inspire health. Serve with compassion. Be the difference.

Professional nurse who has clinical experience with medically complex children and families. Targets pediatric populations to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. Accountable and responsible for direct and indirect patient care across the care continuum, including inpatient, ambulatory, post-acute and patient home settings. Ensures continuity of care through defined, evidence-based methods, including but not limited to medication reconciliation, self-management plans, engagement and education of the patient and/or caregivers, referrals and other interventions.

Provides support/guidance/assistance to other staff in the management of designated populations. Develops care plans and collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction as well as efficient use of resources.

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose:
  Inspire health. Serve with compassion. Be the difference.

• Utilizes the nursing process to coordinate the care of an identified population of pediatric patients throughout the healthcare continuum.

• Performs complete assessment of patient's current health status including barriers and gaps in care.

• Develops a plan of care and self-management plan to meet the needs of the patient and improve clinical outcomes and utilization patterns.

• Coordinates patient and family participation in the development and implementation of the plans.

• Coordinates patient/family education to meet goals.

• Performs home visits as necessary to evaluate possible barriers to the progression of goals.

• Functions as part of the interdisciplinary team across the continuum including acute, post-acute and home settings. Regularly meets with the team to develop a comprehensive plan of care based on the needs of the patient and family. Evaluates and modifies the plan of care as needed.

• Functions as a resource to the community in areas of care coordination and utilization expertise.

• Acts as liaison for families and external agencies and individuals providing services to specific families. Facilitates referrals to other disciplines and internal and community based programs as appropriate to improve outcomes.

• Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRS, NCQA, URAC and HEDIS) when coordinating and facilitating a Plan of Care.

• Increase knowledge of best practices and clinical standards of care and incorporates knowledge into practice.

• Documents in the medical record on-team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.

• Performs other duties as assigned.

• This is a non-management job that will report to a supervisor, manager, director or executive.

• Education - Bachelor's degree in Nursing

• Experience - Three (3) years of experience. One (1) year Care Management/Case Coordination. One (1) year pediatric nursing experience preferred.

• In lieu of the BSN requirement above, an Associate degree in Nursing may be accepted if the applicant agrees to enroll in an accredited BSN or MSN program within one (1) year of their job effective date and obtain a BSN or MSN degree within four (4) years of their job effective date. This in lieu of is only applicable to current employees of Prisma Health or its affiliated companies.

• Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

• A valid driver's license; an acceptable motor vehicle record, as defined by the Acceptable Motor Vehicle Record (MVR) Chart; and proof of auto insurance. Must be willing to travel and have reliable personal transportation.

• Must obtain case management certification (CCM) within 2 years of hire or eligibility to sit for the certification exam.

• NA

Work Shift Day (United States of America)

Location Richland

Facility 7002 Value-Based Care and Network Services

Department  Ambulatory Care Management

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