RN-Care Coordinator - UnityPoint Health

The Care Coordinator integrates and coordinates the clinical care of individuals.  Facilitates the interdisciplinary plan of care to meet multiple service needs, promotes continuity through elimination of fragmentation of care/service and facilitates the effective utilization of resources.  Serves as educator and a central source of communication for the individual and their support systems.

Why UnityPoint Health?  

• Commitment to our Team – We’ve been named a Top 150 Place to Work in Healthcare 2022 by Becker’s Healthcare for our commitment to our team members. 
• Culture – At UnityPoint Health, you Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve. 
• Benefits – Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. 
• Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation. 
• Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience. 
• Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve. 

Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org/  

Care Coordination

• 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.
• Partners with the Social Work team 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.
• 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.
• Integrates with ambulatory care management team, especially with high risk, chronically ill patients.
• Collaborates with patients, caregivers, internal/external healthcare providers, agencies and payers to assist in planning and executing a safe discharge.
• Collaborate with Utilization Management team on continued stay review.
• Educates patients and families regarding available options for care through the continuum.
• Advocates for both the patient and the payer to facilitate positive outcomes for the patient, healthcare team and the payer. If a conflict arises, the needs of the client must be the priority.
• Focuses on the transition of care that includes transfers to and from the hospital to the next level of care setting that is safe, effective, timely and complete. This includes ensuring there are referrals, appointments and information handed off to community services and providers. This may include transitions of care into the hospita, during the hospital stay, during the post-acute care and into the community. 

Plan of Care/Patient Advocacy

• Performs and oversees the assessment, development, and implementation of an individualized plan of care.
• Assesses patient response to treatment and care through other care provider information or by examining patient directly.
• Ensures the plan of care is accessible to the patient and family and assist them in understanding goals of care and movement towards these goals.
• Implements strategies to reduce utilization and length of stay for assigned patients.
• Identifies resources needed for optimal patient care, substantiates the need for resources.
• Communicates changes in the plan of care to the patient and family in a timely manner.
• Negotiates healthcare resources on behalf of the patient.
• Supports patient’s right to make decisions about care and treatment.
• Ensure that the patient’s degree of vulnerability has been captured and documented on the Transitions of Care report.
• Ensures communication with the ambulatory / cross continuum care manager regarding patients who have moderate or red vulnerability at transition.
• Reviews the predictive tool for readmission and documents the risk for readmission. Implements 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.
• Utilizes the med-to-bed program for patients.

Education

• Provides and oversees the education of the patient and family as needed to develop a plan of care.
• Educates patients and families regarding available options for care through the continuum.
• Communicates patient/family learning needs that surface to the direct care nurse. Collaborates with direct care nurse on education plan.
• Refers to content experts as appropriate - i.e. wound care team, Diabetic Educators, Respiratory Therapy or PT.
• Facilitates and documents education related to medication adherence.
• Facilitates and documents patient self-management education.

Utilization Management/Revenue Cycle

• Applies the utilization management (UM) plan by functioning in the UM role as assigned.
• Knowledgeable of utilization criteria used by payers when communicating with the healthcare team and patient. This includes observation, inpatient, and outpatient criteria.
• Demonstrates a working knowledge of financial and reimbursement processes to facilitate medical cost management, including best practices, effective utilization of resources, linking clinical and financial aspects of care, and access to care.
• Serves as a resource and educator to patient, family, staff and physicians regarding financial aspects of individual patient’s resources which may affect the transition of patients through the healthcare system.
• Provides education for the individual and family and for the team regarding benefits, utilization of resources, levels of care, and expectations of the transition process throughout settings across the healthcare continuum. Facilitates empowerment of the patient and family in self-management and health care decision-making.
• Identifies and manages over- and under-utilization of services such as avoidable days or spending.