RN Outpatient Full-time
Shenandoah Medical Center

RN, Chronic Disease Case Manager

Shenandoah Medical Center Shenandoah, IA 51601, US

1. Wellness Prevention & Quality

  • Collaborate with members of the health care team to assist patients with wellness to include wellness exams and healthy living habits.
  • Review registry information for assisting to meet the needs of patients and provide quality of care.
  • Review Quality measures and assist providers and the primary care team to meet and exceed metric benchmarks.
  • Educate patients regarding wellness and prevention to achieve quality of life.
  • Review value-based contract metrics to assist the primary care team to implement workflows assisting patients to achieve quality goals.

 2. Care transitions/ Patient navigation

  • Follow patients through the health care system assisting with transitions with primary care, specialists, and ancillary departments to ensure their understanding of treatment.
  • Introduce patients to available programs –TCM (transitional care management), CCM(chronic care management), PCM (principal care management) and RPM (remote patient monitoring) to assist in self-management of chronic disease and co-morbidities
  • Collaborate with the primary care team, patients, caregivers, and family to ensure patients’ needs are met at the point of care.
  • Assist patient with SDoH (social determinants of health) needs and allocating resources.
  • Lead the primary care team to achieve health equity for all patients seen in primary care.

3. Health coaching/goal setting & care planning

  • Communicate and collaborate effectively with health team members.
  • Educates patients regarding chronic disease & comorbidities, assists with self-management.
  • Identify and recognize abnormal symptoms/changes in patient condition. Appropriately, reports condition changes to medical provider.
  • Encourages adoption of habits that are conducive to a higher quality of life.
  • Utilizes Motivational Interviewing to assist patients in reaching their health care goals.
  • Collaborates with patients to develop patient centered plans.

 4. Performs other duties as assigned.

Share this job

Share to FB Share to LinkedIn Share to Twitter

Related Jobs

RN MDS Full-time
Azria Health Clarinda

MDS Coordinator, RN-$7500 Sign on Bonus

Azria Health Clarinda Clarinda, IA
**$7,500 Sign on Bonus** Azria Health has amazing things happening every day! Do you want to be part of a team that is passionate about providing compassion and quality care for each of our residents? Azria Health is building on the traditions of the past with a focus on the future. It is our belief that Happy Employees make Happy Residents, and here you will find a path to personal and professional growth, a friendly, welcoming atmosphere and an outstanding team. We will provide you the tools and ability to be the best you can be! We have a new opportunity for an MDS Coordinator in a long-term care / skilled nursing facility (LTC / SNF). The chosen MDS Coordinator will have clinical reimbursement, care planning, MDS 3.0, and case mix experience in a nursing environment. We require a Registered Nurse (RN) with strong communication and interpersonal skills for this MDS Coordinator position. Qualifications and Skills We are seeking team members who have the following qualifications and skills: - Professional enthusiastic attitude - Strong communication skills - Self motivated - Shows initiative in daily work Benefits - 401K - Paid Holidays - Paid Vacation - Health/Dental/Vision Insurance Coverage ...and so much more We are an equal opportunity employer. Applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
RN Outpatient Full-time
Sanford Health

RN - Eye Services Clinic

Sanford Health Fargo, ND
$29.50 - $44.50 / hour
Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Facility: 1717 University Building Clinic Location: Fargo, ND Address: 1717 University Dr S, Fargo, ND 58103, USA Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 40.00 Starting Rate: $29.50 - $44.50 Pay Info: $15,000 sign on bonus available for qualified hires Job Summary Answers patient inquiries over the telephone, assessing the severity of the patient's symptoms and medical needs according to triage algorithms. We are seeking a compassionate and skilled Registered Nurse (RN) to join our clinic team. Individuals who thrive in this role are adaptable, great communicators, detail-oriented and have excellent time management skills. These RNs collaborate with providers to guide patients to the appropriate level of care. Your day to day may include: Addressing inquiries via phone and MyChart messaging Providing patient and family education Utilizing nursing and assessment skills Adhering to triage protocols Available for you: A supportive team dedicated to patient-centered care Specialized on-boarding and on the job training Continued growth and development as a RN A fun and fast paced work environment Qualifications Graduate from an accredited nursing program preferred, including, but not limited to, American Association of Colleges of Nursing (AACN), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Bachelor’s Degree in nursing preferred. One year of healthcare experience preferred. 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. Nurses performing nursing practice over the telephone require licensure in the states where the patients being served reside. Within first 30 days of employment, all requirements to obtain license needed for role is completed. Obtains and subsequently maintains required department specific competencies and certifications. Obtains and subsequently maintains required department specific competencies and certifications. Benefits Sanford 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 1-877-673-0854 or send an email to talent@sanfordhealth.org . Sanford 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-0279823 Job Function: Nursing Featured: No
RN Mother-Baby Pediatric Outpatient Full-time
Sanford Health

Registered Nurse - RN - Lactation Consultant - Child Services

Sanford Health Sioux Falls, SD
$31.50 - $44.50 / hour
Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Facility: Child Services Location: Sioux Falls, SD Address: 5015 S Western Ave Suite 120, Sioux Falls, SD 57108, USA Shift: 8 Hours - Varied Shifts Job Schedule: Full time Weekly Hours: 36.00 Salary Range: $31.50 - $44.50 Department Details -Build meaningful relationships with mothers and newborns through continuity of care across both inpatient and outpatient settings. -Provide individualized lactation support and education to families through one-on-one consultations and small group interactions. -Educate and empower patients through prenatal classes, lactation support visits, and community-based support programs. -Deliver comprehensive assessments and personalized education with dedicated time to address each family's unique feeding goals and needs. -Collaborate within a close-knit, supportive team that values teamwork, and shared success. -Join a multidisciplinary team with diverse nursing backgrounds and clinical expertise, fostering professional growth and excellence in patient care. -Make a lasting impact on maternal and newborn outcomes by supporting families during a pivotal stage of life. -Enjoy the opportunity to work in a role that combines clinical expertise, patient education, and relationship-centered care. Job Summary The Lactation Consultant is a professional nurse dedicated to the physical and psychological care of breastfeeding mothers and infants. The consultant's primary responsibility is to facilitate a positive and successful experience with breastfeeding for the patients who are breastfeeding or planning to breastfeed. The Lactation Consultant has knowledge of and utilizes appropriate age-related protocols relating to the physical and psychological needs of patients. Qualifications Graduate from a nationally accredited nursing program preferred, 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). One-year experience in women’s and children’s health services, breastfeeding practices, and understanding the care of a newborn. 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. Basic Life Support (BLS) for health care providers required or within the first 60 days of hire. Current Breastfeeding Counselor Certification (CBC), Certified Lactation Counselor (CLC), or Certified Breastfeeding Specialist (CBS) certification required within 6 months of hire date if not an International Board Certified Lactation Consultant (IBCLC). IBCLC must be obtained when eligibility requirements are met. Benefits Sanford 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 1-877-673-0854 or send an email to talent@sanfordhealth.org . Sanford 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-0279963 Job Function: Nursing Featured: No
RN Manager/Supervisor Outpatient Full-time
Sanford Health

Nursing Supervisor - Registered Nurse - RN - Pulmonary Clinic

Sanford Health Sioux Falls, SD
$36.50 - $51 / hour
Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Facility: Medical Building 2 Location: Sioux Falls, SD Address: 1205 S Grange Ave, Sioux Falls, SD 57105, USA Shift: Day Job Schedule: Full time Weekly Hours: 40.00 Salary Range: $36.50 - $51.00 Department Details Pulmonary Medicine clinic has 7 Physicians and 4 APP's that diagnose, treat and manage a variety of lung and sleep disorders. The clinics hours of operation are Monday -Thursday 8am to 5pm and Friday 8am to 12pm Job Summary Supervises the day to day operations for nursing staff and nursing activities. Functions in a structured care setting and adheres to the policies and procedures established by Sanford. Demonstrate knowledge of nursing principles for the clinic patient. Oversees care for clinic patients of all ages following established standards and practices. Expertly skilled in the functions of the applicable technical software setting and process/utilization improvement. Improves clinical patient care processes for quality patient outcomes. Establishes and maintains effective working relationships with patients, medical staff, clinical support staff and the public. Assists and supports human resources administrative processing and procedures with staff management. May assist with providing feedback in the collection and preparation of required budget information. As needed, monitors inventory levels and supplies for department. Recognizes problems and recommends solutions. Reacts calmly and effectively in emergency situations. Interprets, adapts and supplies guidelines and procedures. Accountable to follow up with risk management and training of clinical staff as needed. Communicates clearly. Maintains confidentiality. Skilled in principles of employee and patient education and change management. Knowledge of common safety hazards and precautions to establish a safe work environment. Must have skills in maintaining records and writing reports. Participates in reviewing results of clinical performance assessments and recommends process improvements. Implements established performance improvement policies and trains employees on these policies. Assists in conducting new staff training and orientation regarding operating rules and working standards. May fill in for clinical support staff when staffing gaps exist. Dependent on staffing needs, may fill in as a point of contact for technical training and troubleshooting for staff. Responsible for utilizing and ensuring staff follow the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care to patients. Responsible for the coordination of care, patient assessment, patient education, triage, and various other nursing interventions. Collaborates with other inter-professional colleagues, including providers to plan, implement and evaluate care. Maintains current certifications in specialty and continues education when necessary as well as tracks and maintains for staff as needed. Learns new concepts, processes and tools related to own personal development and education. 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. Qualifications Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program preferred, 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 hired after January, 2025, 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. Approval from the Nursing Executive for the market is required in order to waive the bachelor degree requirement at time of hire. Additionally for Rural Health Network facilities, for current employees, 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. Three years’ experience as a registered nurse (RN) in a clinical role preferred. Thorough knowledge of the nursing practice act and standards of nursing care, and a working knowledge of administrative and management techniques. 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. Nurses performing nursing practice over the telephone require licensure in the states where the patients being served reside. Obtains and subsequently maintains required department specific competencies and certifications. Certification may be required depending on specialty or service area. Basic Life Support (BLS) is required. Benefits Sanford 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 1-877-673-0854 or send an email to talent@sanfordhealth.org . Sanford 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-0280011 Job Function: Nursing Featured: No
RN Outpatient Full-time
Sanford Health

RN - Registered Nurse - Stress Lab - Full Time Days

Sanford Health Sioux Falls, SD
$32 - $48 / hour
Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Facility: Heart Hospital Location: Sioux Falls, SD Address: 1301 W 18th St, Sioux Falls, SD 57105, USA Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 30.00 Salary Range: $32.00 - $48.00 Department Details Eight hour shifts, three one week, two shifts 2nd week. Monday through Friday. On call every 5th weekend. On call one holiday per year. Job Summary The Outpatient Registered Nurse (RN) is responsible for utilizing the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care to patients. Facilitates health care services for patients in outpatient settings in cooperation with the health care team. Responsible for the coordination of care, patient assessment, patient education, and various other nursing interventions. Collaborates with other inter-professional colleagues, including physicians, to plan, implement and evaluate outpatient care. 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. Qualifications Graduate from an accredited nursing program preferred, including, but not limited to, American Association of Colleges of Nursing (AACN), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Bachelor’s Degree in nursing preferred. 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 licensure, competencies and certifications. Benefits Sanford 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 1-877-673-0854 or send an email to talent@sanfordhealth.org . Sanford 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-0279288 Job Function: Nursing Featured: No