Cross Continuum Care Manager-RN

UnityPoint Health Information

Cross Continuum Care Manager-RN

Des Moines Parks Area Intnl Med

Full-time, M-F 8a-5p

We're seeking a Cross Continuum Care Manager - RN to join our team! 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.

What you will do:

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