[Hiring] Registered Nurse Transition Care @UnityPoint Health

Role Description

The Transition of Care RN is a vital member of the interdisciplinary team, providing telephonic support for post-discharge workflows. This role focuses on transitional care management for patients moving from one healthcare setting to another, most often to the patients’ home. The RN conducts medication reconciliation and assessments to identify patient needs and facilitates referrals to appropriate services. By coordinating care and connecting patients with essential resources along with educating about preventative and supportive measures, the Transition of Care RN helps promote successful recovery and improved health outcomes. The IntelliCenter Transition of Care RN is part of a centralized team with cross functional responsibilities. This position has a Primary Remote designation. Options to work at a designated UnityPoint workspace will be considered upon request and as space becomes available.

Responsibilities

• Monitors and manages appropriate work queues within Epic to support outbound calls to patient populations discharging from a qualifying facility stay.
• Conducts post discharge assessment within appropriate time frame.
• Supports assessment of needs and provides appropriate education and/or identifies resources needed to support a successful transition to home.
• Serves as a resource for providers to help determine referral need, which may include Care Management, Home Health, Hospice, Care at Home, internal disease management programs, or other community-based resource information.
• Provides health information regarding “where to go for care,” chronic disease and medication management education to help reduce preventable exacerbations and unnecessary ED or preventable hospitalizations.
• Documents call criteria in eMR within a timely manner.
• Updates Care Team within eMR with Transitions of Care RN name(s) per market.
• Identifies with shift change requirements as call volume dictates to support staffing needs appropriately.
• The IntelliCenter ToC team supports clinic contingency and therefore will be trained in triage procedures to handle daytime triage requirement.
• Although team members may have a primary market they support, as a centralized department, we share in the responsibility of making sure all market work is completed daily.
• Weekend and holiday rotation.
• Supports change transformation initiatives which lead to process improvement processes to better support UPHs mission.
• Exhibits discretion and sound judgement in all aspects of the job.
• Aids with other reasonable related duties as assigned by supervisor or manager.

Strategic Planning and Clinical Leadership

• Participates and takes personal responsibility to support key strategic initiatives to achieve organizational success.
• Participates and takes personal responsibility to ensure appropriate clinical delivery of programs, keeping within RN scope of practice.
• Is proactive in bringing ideas forward to support a continuous process improvement environment.
• Strive for clinical excellence through professional development activities.
• Represents UnityPoint Clinics in a professional manner.
• Promotes positive interpersonal relations and serves as a role model within the department and with UnityPoint Clinic personnel.
• Displays creativity and innovation when making recommendations for improvement in the delivery of services to the customer.
• Works collaboratively and professionally with all staff and supports others development.

Qualifications

• Graduate of an accredited program for Registered Nurses.
• 1-2 years clinical experience in home care and/or ambulatory care.
• Unrestricted Iowa or practicing state license and will maintain secondary licensure to perform role in UPH service areas.

Benefits

• Paid time off, parental leave, 401K matching and an employee recognition program.
• Dental and health insurance, paid holidays, short and long-term disability and more.
• Pet insurance for your four-legged family members.
• Early access to earned wages with Daily Pay.
• Tuition reimbursement to help further your career.
• Adoption assistance to help you grow your family.