Careers With Purpose Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Facility: Sanford Education Campus Building Location: Sioux Falls, SD Address: 1410 W 25th St, Sioux Falls, SD 57105, USA Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 40.00 Salary Range: $32.00 - $48.00 Department Details This is an exciting role working with complex patients transitioning from hospital to home, with the goal of reducing readmissions. The role is autonomous, yet you will be supported by a team of experienced clinicians including certified nurse practitioners, nurse case managers and a social worker/integrated health therapist. We are looking for someone who can provide clinical care management and also organize and lead team functions. Job Summary Demonstrates expertise utilizing the professional nursing process to provide individualized nursing care. Patient education is individualized to patient needs and condition, provider instruction. Care planning is individualized to patient needs and conditions and ensures it is updated. Assists with the coordination of patient care across the continuum by collaborating with physicians, advanced practice providers, staff and other professionals. Is a liaison with the healthcare team, and serves as a link to community resources. Collaborates with clinical teams managing ambulatory risk registry that identifies high and rising risk populations. Works with the clinical team and may assist or conduct the pre-visit chart review to prepare for a comprehensive patient visit by identifying health care needs based on the approved guidelines. A sampling of the duties performed include, but are not limited to, patient assessment, data collection for research, patient education, goal setting and care planning, preparation for recommended testing; and following through with results. Must be self-motivated, self-directed, and autonomous; willing to teach the healthcare team; and seeks professional development in area of expertise. Able to facilitate patient advocacy efforts. Knowledgeable about healthcare reimbursement models and the application for individuals, groups, and providers. Provides specialized, multidisciplinary patient and family centered education and coordinates off-site education opportunities as needed. Acts as an advocate for patient and families to coordinate care with insurance companies, state and applicable assistance programs and travel arrangements as needed. Support quality improvement and transformation of the health care delivery system. Qualifications Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). For Rural Health Network facilities only, employees who do not possess a Bachelor's degree in the required field, leadership may consider an educational plan with proven continuous action toward achieving a Bachelor's degree in Nursing within five years of hire into position. For current employees in this role, leadership may have considered acceptable qualifications and work experience equivalency based on facility size, rural market, and business need, prior to new Sanford education requirements. Thorough knowledge of the nursing practice act and standards of nursing care, and a working knowledge of administrative and management techniques. Minimum of three years' experience in population health, case management, utilization review, health plan, ambulatory care, or quality management required. Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications. Care Coordination Transition Manager (CCTM) certification required within 18 months of accepting the position. If the CCTM certification is ever on hold or not available, must become a Certified Case Manager (CCM) within 18 months of accepting the position. Basic Life Support (BLS) is required and must be obtained within six months of employment. Must possess a valid driver's license. Benefits Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits . Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-or send an email to . Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment. Req Number: R-0194632 Job Function: Care Coordination Featured: No