RN Cross Continuum Care Manager- Storm Lake Family Medicine Clinics

RN Cross Continuum Care Manager- Storm Lake Family Medicine Clinics

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.

At UnityPoint Health you matter. Were proud to be recognized as a Top 150 Place to Work in Healthcare by Beckers 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 youre 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.

Care Management
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.

Advance Care Planning

Performs outreach utilizing best practices to engage appropriate patients for care management.

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.

Psycho-social support
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.
Access 2-1-1 for community resources or supplement with internal database for community resources not available through 2-1-1.

Communication and coordination between care settings
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.
Identify transition needs when connecting back to PCP
Ensure that patient discharge appointments are consistent with predictive risk of readmission i.e. Heat Map
Ensure consistent care management outreach follow up for those declining Home Care

Education
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.
Coordinates education regarding internal resources and other community support services to the healthcare team i.e. wound care team Diabetic Educators Respiratory Therapy or PT.
Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
Data Analytics
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.
Manages risk stratified patient care including management of patients with multiple co-morbidities or high risk for admission or readmission to a hospital setting using a registry
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. Data includes but is not limited to predictive analysis risk stratification cost-benefit analyses financial analyses; clinical outcomes; utilization and practice patterns
Utilize dashboards or other reporting mechanisms to support performance improvement and outcome evaluation
Implement real time alerts to indicate when individuals are accessing the healthcare system or experiencing issues that could impact their health

Education:

Graduate of an accredited program for Registered Nurses required. BSN preferred.

Experience:

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.

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.

Valid drivers 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
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

Other:

Use of usual and customary equipment used to perform essential functions of the position.
Work may require travel to other UPH or community facilities. May drive a UPH vehicle rental or own vehicle.