Essential Functions

• Assessment: Identifies patients using screening criteria and conduct comprehensive evaluations.

• Care Planning: Develops, adjusts, and coordinates care plans to address medical and social needs.

• Patient Support: Guides self-management using motivational interviewing and coaching.

• Education & Advocacy: Provides education to healthcare teams and patients, advocate for patient rights, and support self-care.

• Collaboration: Works with multidisciplinary teams to ensure timely, high-quality care.

• Process Improvement: Leads initiatives to enhance care transitions and policy adherence.

• Advanced Care Planning: Provides Goals of Care education for informed decision-making.

• Data Analysis & Compliance: Tracks key metrics, analyze trends, and ensure regulatory compliance.

Skills

• Assessment

• Care Planning

• Motivational Interviewing

• Critical Thinking

• Time Management

• Customer Service

• Patient Education

• Communication

• Prioritization

Minimum Qualifications

• Current Registered Nurse (RN) license in state of practice.

• Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of their hire or promotion date. If there is an existing education agreement, that agreement will take precedence.

• Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes.

• Demonstrated understanding of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation.   

Preferred Qualification

• Bachelor of Science in Nursing (BSN) from an accredited institution.

• Case Management Certification

• Demonstrated experience in case management, utilization review, value-based care, and/or discharge planning.

• Basic computer skills, including proficiency in word processing and spreadsheet software. Intermediate knowledge of word processing and Excel software.

Physical Requirements

• Ongoing need for employee to see and read information, labels, documents, monitors, identify equipment and supplies, and be able to assess customer needs.

• Frequent interactions with providers, colleagues, customers, patients/clients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.

• Manual dexterity of hands and fingers to manipulate complex and delicate supplies and equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc.

• Mental stamina and flexibility- ability to handle high stress situations, make quick decisions, and manage multiple tasks simultaneously.

• For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing, and reading signs, traffic signals, and other vehicles.