RegisteredNurse(RN)|CareTransitions

**Location:** Avera at Home Sioux Falls **Worker Type:** Regular **Work Shift:** Day Shift (United States of America) **Pay Range:** _The pay range for this position is listed below. Actual pay rate dependent upon experience._ $31.00 - $46.25 **Position Highlights** **You Belong at Avera** **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.** **A Brief Overview** Manages the care of patients referred to the Care Transitions program. Performs patient assessment and develops a patient-centered plan of care including follow-up phone calls and home visits. Addresses clinical concerns, provides education, makes referrals to appropriate resources and services, assists with access to care, improves care coordination and assures an effective discharge plan for patients at the end of the Care Transitions service. Develops patient care plans in accordance with established protocols. Maintains contact with referring facilities, agencies, and community resources. **What you will do ** * Implements the nursing process utilizing proficient assessment skills in the performance of admission and follow-up phone calls including documentation within the electronic medical record. * Analyzes the assessment data and implements a plan of care individualized to the patient including expected outcomes, including efficient and effective utilization of resources to achieve positive outcomes. * Manages the plan of care according to the patient needs and disease protocols including coordination and referral to home care agencies for home visits. * Provides follow-up outbound phone call assessment and assures appropriate referrals between services upon discharge from the Care Transitions program. * Provides clinical management of patients calling in with symptoms and medical concerns, including appropriate triage. * Makes referrals and works collaboratively with referral sources and community services