UnityPoint Health

Cross Continuum Care Manager-RN

Requisition ID
2720 8th St SW
9010 Administration
Care Management- Ambulatory
Scheduled Hours/Shift
Work Remotely within the US
Work Type (Portal Searching)
Full Time Benefits


This position is open to remote/work from home with strong preference for candidates residing within the UPH geographies of Iowa, Illinois, & Wisconsin.


Will be expected to report in office (Altoona) around 3 days a week.

Must have valid Iowa RN license.



The care manager provides care management and population health services to patients within an assigned region.  The primary target population to serve is the stratified risk patient or patients with high vulnerability at times of transition between care settings.  


Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care team across the continuum, and increasingly use data analytics to manage the health of populations to improve patient access to care and clinical outcomes


COVID-19 and Flu Vaccination Requirement: It is required to be fully vaccinated for COVID-19 and Influenza. Exemption requests based on medical or religious reasons may be submitted, but must be approved for active employment. 


Why UnityPoint Health?

  • Commitment to our Team –We’ve been named aTop 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 like 401K match, paid time off and education assistance 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


Care Management

  • Longitudinal care planning
  • Conducts in depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the stratified risk patients
    • Holistic health care assessment includes: health risks, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
  • Delegates care based on situation while assuming accountability for patient Supports assistive personnel; serves as a resource and holds care team accountable to complete delegated tasks.
  • Develops shared care plan and document on the Common Care Plan to allow access by all care team members across the care continuum.
  • Advance Care Planning
    • Connects patient and surrogate decision maker to ACP facilitation process.
    • Ensure that Advance Care Planning documents are stored and available within the EHR.

Medication Management

  • Reconcile discharge medication orders, medication orders by specialists and PCP. Collaborate with PCP/Interdisciplinary team members on medication changes as needed.
  • Ensure patient understanding of any medications to stop taking or initiate.
  • Be clear to patient why medications were discontinued.


Psycho-social support

  • Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners).
  • Ensure that all members of the care team are aware of barriers, assets, and action plans.

Communication and coordination between care settings

  • Working with the Intellicenter team, physician hospitalists/PCPs/specialists, leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
  • Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families and providers


  • Assesses patient/family knowledge and confidence level of chronic disease self -management and refers to internal and external resources to meet identified gaps.
  • Reinforces education regarding chronic disease self- management utilizing approved action plans, educational materials and best practice recommendations



  • Graduate of an accredited program for Registered Nurses
  • BSN preferred


  • 3 years of clinical nursing experience
  • Previous clinical experience in a clinic/post-acute care preferred.

  • Previous experience with care coordination /care management and population health preferred.


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