Cross Continuum Care Manager-RN

UnityPoint Health Information

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.

What are team member vaccine requirements?

As part of keeping our communities safe and healthy, all team members must be vaccinated for influenza and Tdap, provide proof of immunity to MMR and varicella, and be tested for tuberculosis. New hires must submit proof of vaccination or an approved exemption to begin work. If you have questions, please contact a recruiter or ask at any time during the interview process. UPH strongly recommends that all team members receive the updated COVID-19 vaccine, and at this time, UnityPoint Health - Meriter requires Covid-19 vaccination or an approved exemption.

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.

Care Management

• Longitudinal care planning
• 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
  • Holistic health care assessment includes: health risks, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
• Delegates care based on situation while assuming accountability for patient 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.
• Advance Care Planning
  • Connects patient and surrogate decision maker to ACP facilitation process.
  • Ensure that Advance Care Planning documents are stored and available within the EHR.

Medication 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.
• Be clear to patient why medications were discontinued.

Education:

• Graduate of an accredited program for Registered Nurses
• Bachelors of Science in Nursing (BSN) Preferred
• Basic Life Support (BLS) certification required

Experience:

• 3 years of clinical nursing experience required
• Previous clinical experience in a clinic or Home Care setting preferred
• Previous experience with care coordination /care management and population health preferred

License(s)/Certification(s):

• 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. BLS certification optional for team members that perform the majority of their work at a remote location.
• Valid driver's license when driving any vehicle for work-related reasons

Knowledge/Skills/Abilities:

• 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
• Ability to function effectively as a team leader in a team based environment
• Strong organizational skills and ability to efficiently use tools and resources