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UnityPoint Health Patient Care Facilitator-Care Coordination in Des Moines, Iowa

The Care Coordinator integrates and coordinates the clinical care of individuals. Facilitates the interdisciplinary plan of care in order 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.

Key Accountability—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.

o 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.

o 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.

30%

Key Accountability - Discharge Planning

· 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

30%

Key Accountability - Education

· Optimize utilization of Healthwise for Patient Education

· Communicate patient/family learning needs that surface to the direct care nurse. Collaborate with direct care nurse on education plan.

· Refer to content experts as appropriate i.e. wound care team, Diabetic Educators, Respiratory Therapy or PT.

· Document education related to medication adherence

· Facilitate patient self-management education.

20%

Key Accountability—Revenue Cycle

· 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 and level of 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.

10%

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.

· Care Coordinator 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.

10%

Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.

Education:

Bachelor of Arts/Science degree in health care related field or BSN preferred.

Experience:

Two years of clinical experience in focused areas working with multidisciplinary teams.

License(s)/Certification(s):

Current RN Licensure in state of residence.

Knowledge/Skills/Abilities:

Writes, reads, comprehends and speaks fluent English.

Basic computer knowledge using word processing, spreadsheet, email and web browser.

Other:

Use of usual and customary equipment used to perform essential functions of the position.

Requisition ID: 2019-64474

Street: 1200 Pleasant St

Name: 3020 UnityPoint Health Des Moines

FLSA Status: Exempt

Scheduled Hours/Shift: Day Shift

External Company URL: http://www.unitypoint.org

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