UnityPoint Health
Location
Des Moines, Iowa
The Care Coordinator integrates clinical care for patients in Neurosurgical, Trauma, Orthopedics, Renal, Transplant, and Urology units. They facilitate interdisciplinary plans of care and manage safe transitions and discharge planning to ensure continuity of service.
Candidates must hold an Associate's degree in nursing (ADN) and a current RN license in the state of Iowa. A minimum of two years of clinical experience working with multidisciplinary teams is required.
Screens 100% of adult Medical Surgical In-patient and observation patients and assesses the individual’s health status including clinical conditions, support systems and resources to identify needs and make referrals to appropriate multi-disciplinary services. Prioritizes patients for care coordination based on defined criteria. Monitors and coordinates an interdisciplinary plan of care in partnership with the individual and their support services for needs and services across the health care continuum and for transition through the levels and locations of care. Assumes accountability for the development and implementation of an effective discharge plan for complex care patients. Works with internal and external resources to co-ordinate a timely safe transition of patient to the appropriate level of care. Lead and participates with the interdisciplinary team in daily rounds, planning delivery and evaluation of patient-focused care for prioritized patients. Documents the case management plan to include: clinical needs, barriers to quality care, effective utilization of resources and pursues denials of payment and referrals in a timely, legible manner. Tighter integration with ambulatory care management team, especially with high risk, chronically ill patients. Standardize alert to cross continuum care managers when patients are admitted Works closely with providers for discharge planning and determining the next level of care Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge Collaborate with Utilization Management team on continued stay review. Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to plan and execute a safe discharge Identify and facilitate post-acute resource needs: Home Care, Community based Referrals, Diagnostic testing, Outpatient Therapies (Pulmonary Rehab, Cardiac Rehab, Physical and/or Occupational Therapy), Palliative Care or Hospice. Ensure that the patient’s degree of vulnerability has been captured and documented on the Transitions of Care report. Ensure verbal communication with the ambulatory / cross continuum care manager regarding patients who have moderate or red vulnerability at transition. Document who will assume the care coordination/management role for these patients and for what period of time in the Common Care Plan and the Transition of Care report, if known. Review the predictive tool for readmission and document the risk for readmission. Implement additional interventions to mitigate the risk for readmission such as two follow-up appointments – one at the time the predictive tool indicates the patient is at highest risk for readmission Facilitate reconciliation of discharge medication orders, alert PCP staff to In-Patient /Out Patient formulary changes Utilize the med –to-bed program for patients with poly pharmaceuticals
Education: Associate’s degree in nursing (ADN) Experience: Two years of clinical experience in focused areas working with multidisciplinary teams License(s)/Certification(s): Current RN Licensure in state of Iowa Other: Dept of Labor Level 2 Work: Exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Requires walking or standing to a significant degree, pushing or pulling arm or leg controls or maintaining a production rate pace. Light work requires physical exertion of forces greater than that of sedentary work.
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