RN - Transitions of Care

Dubuque, IA

Monday-Friday 8:00AM-5:00PM

Full Time Benefits

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 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. 

At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.  

Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.  Here are just a few:      

• Expect 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. We even offer pet insurance for your four-legged family members.  

• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.   

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.  

And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. 

Find a fulfilling career and make a difference with UnityPoint Health. 

Operations
• 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. This may include additional shift requests or the need to flex off or support Rx Renewal and triage calls depending on volume and need.
• 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.

Education

The Transition of Care RN will be a graduate of an accredited program for Registered Nurses

Experience

1-2 years clinical experience in home care and/or ambulatory care.

License(s)/Certification(s)

The Transition of Care RN will have an unrestricted Iowa or practicing state license and will maintain secondary licensure to perform role in UPH service areas.

Knowledge/Skills/Abilities

• Must have proficient keyboarding/typing skills and have a technical aptitude to learn new computer software systems quickly.
• Ability to handle a “call center” environment: work quickly and multi-task; use critical thinking skills while navigating computer software, build fluidity and proficiencies in these skills to meet required turnaround time which supports patient care delivery objectives and operational costs.
• Ability to handle confidential and sensitive information.
• Ability to communicate effectively on the telephone.
• Ability to relate to persons with diverse educational, socioeconomic and ethnic backgrounds.
• Ability to demonstrate good customer service.
• High level of accountability, adaptability, and collaboration
• Business Acumen and effective communication skills, both written and verbal, interpersonal skills, problem solving, teamwork, and professionalism
• Strong decision making with patient focus
• Flexibility within hours and throughout the day’s assigned work. Microsoft familiarity and strong technical aptitude including the ability to learn new systems quickly