RN Cross Continuum Care Manager- Sac City, Lake View, Pocahontas, and Laurens Family Medicine Clinics

UnityPoint Health • Sac City, IA

91d

About The Position

The care manager provides care management and population health services to patients within an assigned region. The primary target population to serve is the stratified risk patient or patients with high vulnerability at times of transition between care settings. Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care team across the continuum, and increasingly use data analytics to manage the health of populations to improve patient access to care and clinical outcomes.

Requirements

• Graduate of an accredited program for Registered Nurses required. BSN preferred.
• 3 year clinical nursing experience required.
• Previous clinical experience in a clinic or Home Care setting and previous experience with care coordination/care management and population health.
• Current license in good standing to practice nursing in the state where care is provided.
• Basic Life Support (BLS) certification required for team members that perform the majority of their work in the clinic setting.
• Valid driver’s license when driving any vehicle for work-related reasons.

Nice To Haves

• Basic computer knowledge using email, web browser and documentation of care in an electronic health record.
• Knowledge of the healthcare system and resources available to patients.
• Strong clinical proficiency and ability to apply critical decision making in dynamic situations.
• Motivational Interviewing and applies Integrated Chronic Care Management skills.
• Cultural compliance.
• Trauma informed care.
• Ability to problem solve in complex situations.
• Strong interpersonal skills and ability to collaborate.
• Excellent communication skills-written and verbal.
• Strong self-motivation and ability to work independently, setting priorities to coordinate care plan efficiently.
• Proven leadership skills.
• Ability to function effectively as a team leader in a team based environment.
• Patient focused.
• Excellent customer service skills.
• Strong organizational skills and ability to efficiently use tools and resources.
• Ability to perform multiple tasks.
• Effective behavioral and educational strategies, including, but not limited to, motivational interviewing, teach-back method and self-management support.

Responsibilities

• Conducts in depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the stratified risk patients.
• Delegates care based on situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and holds care team accountable to complete delegated tasks.
• Develops shared care plan and document on the Common Care Plan to allow access by all care team members across the care continuum.
• Performs outreach utilizing best practices to engage appropriate patients for care management.
• Reconcile discharge medication orders, medication orders by specialists and PCP. Collaborate with PCP/Interdisciplinary team members on medication changes as needed.
• Ensure patient understanding of any medications to stop taking or initiate.
• Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners).
• Ensure that all members of the care team are aware of barriers, assets, and action plans.
• Working with the Intellicenter team, physician hospitalists/PCPs/specialists, leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
• Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families and providers.
• Functions as a coordinator and manager of a defined health population across multiple care settings and for multiple physicians/health care providers or health plan counterparts.
• Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.
• Participate in Readmission Root Cause Analysis.
• Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting.
• Assesses patient/family knowledge and confidence level of chronic disease self-management and refers to internal and external resources to meet identified gaps.
• Reinforces education regarding chronic disease self-management utilizing approved action plans, educational materials and best practice recommendations.
• Identify appropriate risk stratification via EHR encounters or datasets to intervene as appropriate.
• Integrate patient registry, stratification and other tools/reports to identify patients who may be appropriate for care management.
• Analyzes data to identify under/over utilization; improve resources consumption; promotes potential reduction in cost; and enhances quality of care consistent with organization strategic goals and objectives.

Benefits

• Paid time off.
• Parental leave.
• 401K matching.
• Employee recognition program.
• Dental and health insurance.
• Paid holidays.
• Short and long-term disability.
• Pet insurance.
• Early access to earned wages with Daily Pay.
• Tuition reimbursement.
• Adoption assistance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree