RN-Pt Care Cdtr-Rehab/Pain Clinic

Care Coordination-

· Ensures the provision of care serving as the liaison between the patient, rehabilitation team and external resources.

· Provide coordination of services, ensuring adequate discharge plans are in place.

· Facilitate the collection of documentation from multi-disciplined specialists into the shared treatment plan for quick review of the current plan of care from one discipline to another.

· Ensures documentation is dispersed to all care team participants including referring provider and/or PCP.

· Communicates with internal and external resources and the persons served to ensure achievement of outcomes.

· Facilitates orientation that is appropriate to the services and the outcomes predicted for the persons served.

· Facilitates involvement of the persons served throughout the individual pain management plan.

· Ensures that learning needs identified for the persons served are met in a coordinated, comprehensive manner.

· Monitors coordination of care for appropriate intervention and use of preventive measures through team conference interaction, individual staff/patient education/communication and other record reviews.

· Assist persons served in navigating their care experience with chronic pain.

· Coordinate care and follow-up appointments, making sure persons served has completed tasks/attended appointments.

· Coordinate the timing of annual visits with the care team and assist in determining insurance coverage for individual and group session included in the pain management services.

· Assist the multi-disciplinary team in communicating and collaborating regarding patients’ goals of care.

· Provide outreach to UnityPoint Clinics and other community partners to educate and provide knowledge regarding non-opioid treatment strategies offered by the St. Luke’s Rehab and Pain Center.

· Help to identify patients who have chronic pain and comorbid substance use disorder/mental health issues.

· Identify at-risk patients who are currently on opioid-therapies for chronic pain.

· Provide education regarding evidenced-based treatments for chronic pain offered by St. Luke’s Rehab and Pain Center.

· Coordinate and assure communication with physicians regarding patients’ progress toward outcomes in the pain management plan of care.

· Regularly reviews with the persons served their progress toward goals and seeks input to relay to the treatment team.

· Facilitate the setup of individual patient remote visits and group sessions.

· Partner with psychologist on any imminent risk detected to ensure patient safety, assisting with transferring patient to higher level of care.

· Capture, assess and/or verify the collection of behavioral health questionnaire and load into the Epic chart for provider review alerting provider of any points of concern that need immediate intervention.

· Compile, track, and analyze data for reporting patient outcomes.

· Understand and troubleshoot technologies associated with remote/telehealth visits.

Outreach-Pain Center Development

· Serve as a liaison to promote the St. Luke’s Rehab and Pain Center services to increase awareness and patient referrals to the program.

§ Connect with primary care providers and other referral sources to promote the tools within the St. Luke’s Pain Center and communication of individual care plan in a clear, concise, actionable method.

§ Work with marketing and administration on campaigns that highlights and promote awareness of the St. Luke’s Rehab and Pain Center.

· Performs utilization management and quality review activities on all inpatient rehabilitation patients, assuring patients are receiving the appropriate level of care.

· Outcomes measurement:

§ Facilitates the gathering of appropriate information to assist in the follow-up activities of the pain center in its analysis of program performance.

Basic UPH Performance Criteria

· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.

· Demonstrates ability to meet business needs of department with regular, reliable attendance.

· Employee maintains current licenses and/or certifications required for the position.

· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

· Completes all annual education and competency requirements within the calendar year.

· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.

Minimum Requirements

Identify items that are minimally required to perform the essential functions of this position.

Preferred or Specialized

Not required to perform the essential functions of the position.

Education:

· Graduate of an accredited nursing program.

· Bachelors’ degree (preferred) with current RN license

Experience:

· Minimum of 3 years clinical experience (required).

· Experience in Rehabilitation nursing.

· Experience in an interdisciplinary rehabilitation model (preferred).

License(s)/Certification(s):

· RN license in State of Iowa.

· CRRN, CCM or equivalent certification preferred

· CCRN preferred

Knowledge/Skills/Abilities:

· Writes, reads, comprehends and speaks fluent English.

· Basic knowledge of Rehabilitation theory and practice.

· Understands and applies human relation skills in individual and group interactions.

· Participates in appropriate professional organizations

· Must possess strong verbal and written communication skills.

· Professional and personal effectiveness in establishing relationships with referral sources, payers, clinical providers and patients/caregivers.

Other:

· Must be able to work well with all customers, associates and co-workers.

· Must demonstrate a cooperative, courteous and dependable working performance.

· Must possess high integrity and maintain confidentiality at all times.

· Must be able to delegate effectively.