Essential Functions & Responsibilities
- Coordinate and facilitate patient centered interdisciplinary care and communication, including home health and referring physicians’ around interventions leading to the best outcome.
- Provide regular and consistent follow-up during transitions of care with patient, coordinators and other healthcare professionals in other care settings; including Care Navigators and Patient Care Facilitators.
- Coach and educate designated patient population and family regarding chronic disease self-management and preventative health maintenance using predefined protocols and evidence based medicine.
- Work with patients and families to develop and work towards self-management goals through RN only visits.
- Empower patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary utilization.
- Provide consolidated information regarding internal and external resources and services including home health and other community support services to patients/families as well as the healthcare team.
- Support provider in meeting chronic and preventive health care needs by guiding patients in collaborative self-management.
- Proactively assist providers and other healthcare team members as patient advocate, ensuring progress toward goal attainment.
- Utilize patient registry tools to guide action plan for designated patient populations.
- Identify high-risk patients and intervene with the guidance of the provider to improve outcomes
- Previous clinical experience in a medical office preferred.
- Previous clinical experience with an electronic health record preferred.
- Previous experience with process improvement initiatives preferred.
- Previous experience in Care Coordination preferred.
- Current CME certification for current license to practice nursing in the State of Iowa for Registered Nurse.
- Must be able to demonstrate the ability to interact effectively with physicians, health care team members, individuals, and members of their support systems.
- Must be able to work independently and assume responsibility for timely completion of assigned functions.
UnityPoint Health - 30+ days ago