Overview:
Coordinates patient care across the acute care continuum by partnering with physicians, nursing, social services, and ancillary teams to develop and implement an interdisciplinary plan of care. Conducts admission and ongoing assessments, monitors clinical progress and resource utilization, and leads safe transitions of care, including discharge planning and referrals to community services. Educates patients and families, addresses psychosocial and social determinants of health barriers, and collaborates with Utilization Management regarding level of care considerations. Serves as the central communicator to promote collaboration, continuity, and achievement of defined outcomes such as reduced readmissions and optimized length of stay.
Why UnityPoint Health?:
At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.
Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few:
- Expect paid time off, parental leave, 401K matching and an employee recognition program.
- Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
- Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.
With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.
And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.
Find a fulfilling career and make a difference with UnityPoint Health.
Responsibilities:
Care Coordination and Discharge Planning:
- Screens and assesses patients to identify clinical, psychosocial, financial and legal concerns that affect recovery and transition needs
- Prioritizes patients for care coordination using screening tools.
- Develops and coordinates an individualized plan of care
- Supports interdisciplinary care rounds and documents the plan in the medical record
- Collaborates with patients, families, providers, nursing, social work, payers, and agencies to eliminate barriers, arrange services, and execute safe transitions across levels and locations of care
- Coordinates access to post-acute resources including home care, equipment, medications, therapies and follow-up appointments
- Provides thorough handoff to the next care team
- Monitors progression of care, avoidable days and length of stay targets
- Escalates issues that may result in failed discharge or readmission
- Maintains thorough and timely documentation of assessments, plans and interventions to ensure continuity and regulatory compliance
Regulatory Compliance:
- Administers and/or delegates administration of Medicare notices per regulatory guidelines.
- Collaborates with Utilization Management specialists
- Coordinates pre-authorization for diagnostic tests, procedures and treatments with payers
- Communicates Utilization Management determinations impacting discharge planning and resource utilization with the care team.
- Functions as a resource for external agencies requiring clinical review of patient conditions and care
Patient and Family Education:
- Assesses patient and family learning needs and readiness
- Formulates and updates individualized teaching plans in coordination with the care team and evaluates outcomes
- Facilitates education regarding disease process, treatment plan, medications and self-management; empowers patients and families to utilize healthcare resources appropriately
- Provides ongoing education throughout hospitalization and transition, reinforcing discharge instructions and coordinating community resources to support continuity of care
- Acts as a clinical resource and mentor to staff on care coordination practices, criteria application and documentation standards
Quality of Care and Performance Improvement:
- Monitors readmissions, length of stay, avoidable days and other indicators
- Identifies trends and implements improvement opportunities with multidisciplinary partners
- Performs quality data collection and reporting as assigned
- Supports development of policies and forms to meet regulatory and documentation requirements
- Engages in process improvement initiatives to enhance patient flow, effectiveness of care coordination and transitions of care
- Supports and coaches accurate clinical documentation by physicians and the healthcare team to optimize outcomes and compliance
Qualifications:
- Graduate of an accredited nursing program - ADN or BSN
- Valid RN License in the State of Iowa in good standing
- 3 Years Clinical RN experience in acute care or hospital settings, collaborating with multidisciplinary teams and caring for specific patient populations