Registered Nurse #74847

Company: Alberta Health Services

Job Description


  • Using advanced case management skills, proactively identifies clients who may have unmet needs on discharge, or who may need to transition to another level of care when acute concerns are resolved.
  • Gathers information employing appreciative inquiry questioning techniques.
  • Completes initial standardized assessment including the InterRAI Contact Assessment and other tools where appropriate.
  • Identifies the need for Continuing Care services such as Home Care, Supportive Living or Long Term Care through collaboration with Client, Family and Health Care team.
  • Collaborates with Intake Nurse-Continuing Care Access to confirm AHS Continuing Care services availability, (including Home Living, Supportive Living and Long Term Care).
  • Collaborates with Placement Coordinators regarding clients who may require an alternate level of care on discharge.
  • Provides information, professional advice and referrals as necessary to other agencies as appropriate.
  • Articulates roles and expectations of care team members, including Client and Caregiver expectations.
  • Documents care including Contact RAI and other relevant assessments in the appropriate systems.
  • Using a Client centered approach, works with the Client, Family and formal care providers to anticipate service needs, consider options and make appropriate recommendations and referrals.
  • Collaborates with the Client, Family and Interdisciplinary Care Team to identify anticipated unmet needs.
  • Applies knowledge of services available to Clients via AHS, especially those within the North Zone.
  • Explore alternatives for meeting unmet needs which may include formal supports, community resources and the Client’s own personal resources.
  • Consider the needs and preferences of the Client and Family while balancing available formal and informal resources.
  • Identify potential functional or medical needs that may require preventative planning to minimize potential readmission.
  • Identifies initial service needs, equipment and supplies, and determines if they are available in the community in question.
  • Anticipate service delivery processes and required resources.
  • Determines, in collaboration with Client, Family and Care Team, the most appropriate team member or services option to address unmet needs, concerns or issues.
  • Make appropriate referrals or consultations, including to the Continuing Care Access for Intake and Screening.
  • Provide health services information and provide linkages to appropriate community agencies for unmet needs that cannot be addressed by Continuing Care Services.
  • Facilitates the process of discharge home or transitioning to another care setting.
  • Proactively manages transitions across the continuum by initiating and maintain communication of pertinent information.
  • Assists the Client in navigating and negotiating the health care system by providing relevant contact information with other programs and providers.
  • Follow best practices related to transfer information.
  • Anticipate disengagement and facilitates transitions to new Care Provider(s).
  • Provides services over extended services hours.


  • Graduation from a recognized Nursing Education program, Baccalaureate degree in nursing preferred.
  • Additional preparation in Case Management, Seniors’ Health, Gerontology or Palliative Care considered an asset.
  • Active registration and practice permit with the College and Association of Registered Nurses of Alberta (CARNA).
  • Minimum 5 years in an acute care setting.
  • Home Care, Seniors’ Health, Discharge Planning and Placement or related experience an asset.
  • Experience in a rural setting will be considered an asset.
  • Demonstrated skills in problem solving, Case Management, interpersonal relationships and organizational leadership are required.
  • Current BCLS- HCP certification required.
  • Knowledge of RAI assessment tools is considered an asset.
  • Completion of the AHS Case Management Education is considered an asset.
  • Excellent ability in Care Management and coordination an asset.
  • Ability to work in a fast-paced environment; ability to be flexible to time commitments and to meet the needs of Clients in the Home Care program.
  • Ability to work with people in the Health Care environment with professionalism and respect.
  • Ability to communicate effectively both verbally and in writing.
  • Proven interpersonal skills and the ability to get along with a wide variety of people.
  • Proven organizational, time management and sound decision making skills required.
  • Proven imitative and motivation required.
  • Ability to meet the physical demands of the position.
  • Reliable, flexible, dependable and punctual.
  • Ability to provide a positive and friendly approach that will enable you to deal with challenging situations with empathy and sincerity.
  • Ability to work effectively independently, and within a team, effectively managing his or her time and setting priorities when faced with multiple tasks and deadlines over a period of time.
  • Ability to learn and receive constructive criticism.
  • Demonstrable problem solving and conflict resolution skills/training.
  • Proven ability to cope with stress and deadlines in an efficient and effective manner.
  • AHS values the diversity of the people and communities we serve and is committed to attracting, engaging and developing a diverse and inclusive workforce.
  • All employees must provide a criminal record check that is satisfactory to AHS in compliance with the AHS Security Screening Procedure.
  • All employees who work in a patient care location are required to submit a completed Communicable Disease Assessment form.
  • All professions must provide proof of licensure or registration with the approved Alberta regulatory college, prior to commencing duties with AHS where applicable: Regulated health professions under the Alberta Health Professions Act and Health Disciplines Act will be required to provide an original copy of a valid practice permit before commencing their duties with AHS. Other professions governed by government acts, college or regulatory body requirements may be required to provide additional documentation.

Additional Information:

In addition to a competitive rate of pay, AHS currently has a Fort McMurray Allowance in place to an annual maximum of $12,480. This allowance is non-pensionable and is payable on an hourly basis for all hours paid at the basic rate of pay.

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