Population Health Registered Nurse Case Manager
Full Time Benefits
The Population Health RN Case Manager uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver high quality patient care in the patient’s place of residence. The Population Health RN Case Manager develops and oversees the home health plan of care under the direction of the physician and ensure appropriate interdisciplinary involvement to ensure the best outcome for each patient. The Population Health RN Case Manager delivers patient care directed by the physician as established in the home health plan of care that is consistent with clinical best practices and results in high quality, improved outcomes and exceptional patient experience.
The Population Health RN Case Manager works with the home care clinical leadership team to ensure coordinated patient care delivery by assisting with oversight of patient care delivery and facilitation of care coordination. As a member of the interdisciplinary team, contributes professional nursing knowledge and skills in the provision and management of care to patients and their families. Maintains a practice environment that reflects the ANA Code for Nurses, Philosophy of Nursing at UnityPoint Health with in the structure of the Professional Nurse Practice Model and in collaboration with other care givers.
Why UnityPoint Health?
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Essential functions are the duties and responsibilities that are essential to the position (not a task list). o not include if less than 5% of work time is spent on this duty. Be specific without giving explicit instructions on how to perform the task. Do not include duties that are to be performed in the future. Duties should be action oriented and avoid vague or general statements.
% of Time
Patient Care/Care Coordination
· Makes visits to the homes of patients requiring home health nursing services and assumes responsibility for an ongoing interdisciplinary assessment of the patient.
· Daily IDT calls
· Spoke calls
· Coordinate visits with HomeCare admissions
· PRN patient visits
· Monitor Patient vital signs via tele-health platform as directed per physician.
· Assesses the needs of patients and families, providing appropriate teaching and making the necessary referrals to provide continuity of care.
· Integrates and coordinates the care of the at-risk population across the healthcare continuum.
· Communicates clinical status and plans clearly, succinctly and accurately to interdisciplinary care team, administrative support team, leaders, and physicians.
· Conferences with clinical management, physician and interdisciplinary team in order to provide high quality, cost effective care.
· Delegates and provides direction for other healthcare providers and hold them accountable for their involvement in the plan of care.
· Utilizes critical thinking in making independent judgments and maintains responsibility and accountability for the knowledge of conditions of assigned patients.
· Identifies risk for acute hospitalization and proactively prevents adverse events.
· Performs initial and comprehensive assessments on all patients in accordance with agency policies and procedures.
· Promptly completes documentation to assure an accurate legal record of patient’s care and time and travel entries
· Performs nursing assessment at each visit in accordance with agency policies and procedures.
· Ensures quality and safe delivery of services to patients according to the care plan.
· Uses equipment and supplies safely, effectively, and efficiently.
· Promotes patient independence by teaching patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician:
o Treatment and disease management
o Medications purpose, use, side effects, potential adverse effects
o Proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided
o Patient plan of care
o Emergency preparedness
· Provides the services that are ordered by the physician as indicated in the plan of care.
· Provides patient, caregiver and family counseling and education as indicated in the plan of care.
· Develops and continually updates a plan of care that specifies the care and services required to meet patient-specific needs determined during the comprehensive assessment and includes measurable outcomes that will occur as a result of implementing and coordinating the plan of care.
· Develops and updates patient’s discharge plan on every visit ensuring patient and caregiver education and training is facilitating timely discharge and measurable goals and outcomes are attainable, realistic and up-to-date.
· Includes the patient, representative and caregiver in all plan of care decisions.
· Assesses the need for plan of care updates and every visit and includes the patient and family in care planning decisions and communicates care plan revisions to the patient, representative, caregiver and all physicians issuing orders for the home health plan of care.
· Maintains accurate and timely documentation of clinical records and time/travel entries.
· Receives, relays and documents verbal orders in accordance with state and federal regulations and in a timely manner to prevent adverse patient outcomes.
· Is responsible for obtaining physician orders prior to initiation of care and notifying the physician of any changes in the patient’s condition.
· Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care.
· Identifies patient’s risks for hospitalization and/or emergency department use and proactively intervenes to prevent adverse events.
· Collaborates with clinic partners for ongoing best practice implementations and revisions to program.
· Supervises home health aide and licensed practical nurse staff and documents supervision in the patient medical record.
· Performs “on-call” duties and weekend/after hour visits on a rotational basis as assigned.
· Performs other duties as requested by supervising leader to facilitate smooth and effective operations of the organization.
Home Care Performance Criteria
· Delivers quality care and completes clear, concise and accurate clinical documentation of care provision in accordance with home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential and the home health plan of care.
· Maintains competence in OASIS data collection and documentation and submits all initial and corrected assessments according to CMS guidance and agency policies and procedures.
· Participates in clinical review of records to monitor quality and accuracy, appropriate utilization, appropriate involvement of interdisciplinary team members, appropriate referrals and coordination of care.
· Participates in peer review and other quality assurance activities, as assigned.
· Uses appropriate infection control procedures and safety measure to protect employees and patients.
· Provides patient and family education using UPaH approved patient teaching materials only.
· Provides patient, family, and/or caregiver education and information pertinent to diagnosis and safety issues.
· Participates as a member of the interdisciplinary team.
· Participates in quality assurance/performance improvement (QAPI) activities, as assigned.
· Maintains professional knowledge for discipline/credential/license ensuring inclusion of content specific to home and community-based care.
· Communicates professionally, effectively and timely to all team members and co-workers and responds to all communication in a timely manner including, but not limited to e-mails, phone communication and meeting follow-up responsibilities.
· Establishes and maintains positive interpersonal relationships with team members, patients and family members while maintain personal and professional boundaries.
· Assist with new employee orientation when necessary.
· Effectively plans, organizes, sets priorities and completes works assignments with minimum direct supervision per agency policy and within established time frames.
· Maintains productivity standards as defined by home care supervisor.
· Meets or exceeds agency expected outcomes related to patient experience and hospitalization utilization.
· Participates in evening, night and weekend coverage to ensure nursing services are accessible to all patients 24 hours a day, 7 days per week (schedules and rotations determined by region).
· Performs other duties as assigned by home care clinical supervisor and/or administrator.
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.
· Employee 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 administrative staff.
· Takes appropriate action on concerns reported by department staff related to compliance.
· Maintains compliance with Personnel policies and procedures.
· Behaves in a manner consistent with all Corporate Compliance policies and procedures.
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.
Demonstration of UPH Values and Standards of Behaviors
Consistently demonstrates UnityPoint Health’s values in the performance of job duties and responsibilities
· Leverage the skills and abilities of each person to enable great teams.
· Collaborate across departments, facilities, business units and regions.
· Seek to understand and are open to diverse thoughts and perspectives.
Own The Moment:
· Connect with each person treating them with courtesy, compassion, empathy and respect
· Enthusiastically engage in our work.
· Accountable for our individual actions and our team performance.
· Responsible for solving problems regardless of the origin.
· Commit to the best outcomes and highest quality.
· Have a relentless focus on exceeding expectations.
· Believe in sharing our results, learning from our mistakes and celebrating our successes.
· Embrace and promote innovation and transformation.
· Create partnerships that improve care delivery in our communities.
· Have the courage to challenge the status quo.
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
Graduate of State Board approved program for Registered Nurses and valid license as RN in state(s) where providing care.
One year nursing experience caring for similar patient population as to be assigned.
Home care experience
2+ years nursing experience
Valid licensed driver with automobile insurance in accordance with state(s) and/or organizational requirements.
Mandatory Reporter: Child & Dependent Adult Abuse.
Person Centered Care (PCC) course completion within first 12 months of hire and annual completion of competency validation activities.
CPR: Maintain a valid Basic Life Support (BLS) Healthcare Provider Card with Re-certification.
ANCC certification in area applicable to home care patient population
Basic knowledge of current, frequently used medications, including modes of administration, actions and side effects.
Competency in variety of nursing skills and ability to perform without supervision (NPWT, complex wound care, IV therapy, catheter care, ostomy care, chronic disease management assessment and teaching).
Strong interpersonal skills.
Ability to work as a collaborative team member.
Ability to understand and apply guidelines, policies and procedures.
Ability to navigate and perform basic use of Microsoft Office products.
Maintains a reliable mode of transportation and has the ability to drive safely during all day and night hours and in all types of inclement weather.
Experience with documentation in an electronic health record.
Use of usual and customary equipment used to perform essential functions of the position.