To provide care coordination across the care continuum from inpatient to outpatient settings while assessing needs and optimizing adherence by identifying and overcoming barriers such as language, cognitive, cultural, social, financial, environmental, psychological, no motivation and personality disorders along with overall chronic illness management.  Mobilizes appropriate community referrals and resources as indicated and provides detailed, recurrent patient and family education.  Involved in program development for both inpatient and outpatient settings and with interpretation of program metrics.  

At UnityPoint Health, you matter. We’re proud to be recognized as a Top 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 focused on 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, health and vision 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.

Join our team of experts and make a difference with UnityPoint Health.

Clinical Excellence and Coordination

• In collaboration with the Heart Failure / Pulmonary Hypertension Medical Director / Interdisciplinary team works to coordinate diagnostic, therapeutic treatment plans and educational efforts for inpatient / outpatient patients.
• Provide and coordinate care / communication with referring physicians and offices to facilitate appropriate referrals to the program
• Provide regular and consistent follow up during transitions of care with patient/ family, coordinators, and other health professionals from one health care setting to another.
• Deliver high quality care utilizing the nursing process while demonstrating knowledge and clinical skills of the specialty in accordance with established policies, procedures and standards of care.
• Provide advanced medication reconciliation in complex, frequently changing regimens.
• Adjust diuretics using physician developed and approved protocols
• Adjust Beta Blockers using physician developed and approved protocols
• Assist with coordination of care with drug manufacturers and pharmacies to obtain medications and patient assistance when necessary. 
• Assessing and optimize home medication delivery systems.
• Set periodic RN initiated phone surveillance contacts.
• Optimizing adherence by identifying and overcoming barriers such as language barriers, cognitive barriers, cultural barriers, no motivation, personality disorders and poor health literacy.
• Cultivate support systems to improve outcomes
• Participate in evaluation and care of Program hospitalized patients, and patients having Outpatient Infusion therapy.
• Provide emotional and psychological support for patients and families with advanced chronic illness
• Provide clinical and laboratory follow up of patients after initiation of specific therapies.
• Provide appropriate and timely documentation in the patient’s electronic health record using standardized workflow processes.

Development and Education

• Provide detailed and recurrent patient / family education in home health surveillance techniques and diet and fluid restriction
• Identify barriers for nonadherence and work toward resolution
• Develop Heart Failure / Pulmonary Hypertension Program for both inpatient and outpatient settings which includes education of hospital / clinic staff in appropriate assessment, referral and use of different medication protocols for patients including ongoing monitoring.
• Provide comprehensive education about medication management and action to be taken with complications.
• Provide support and teaching as it relates to diagnosis, disease process and discharge while in hospital.
• Provide mandatory educational sessions including didactic conferences, clinical discussions and web based learning.
• Obtain advanced certification in practice area encouraged (AAHFN)
• Participate and / or assist with research studies related to Heart Failure / Pulmonary Hypertension.
• Continues professional development and involvement in professional activities that enhance nursing practice by sharing knowledge through networking and research.
• Participate in inpatient / outpatient Heart Failure / Pulmonary Hypertension Committee and Program development work

Leadership
• Demonstrate clinical leadership as a role model for other staff and provide direction that ensures top of licensure for all team members.
• Utilize critical thinking in making independent judgements related to patient care. Maintain responsibility and accountability for the knowledge of conditions of assigned patient populations.
• Engage in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided.