UnityPoint-St Luke's
Part-Time WEEKEND PACKAGE
Friday 4pm-8pm, Saturday and Sunday 8am-4:30pm
Coordinates patient care across the acute care continuum by partnering with physicians, nursing, social services, and ancillary teams to develop and implement an interdisciplinary plan of care. Conducts admission and ongoing assessments, monitors clinical progress and resource utilization, and leads safe transitions of care, including discharge planning and referrals to community services. Educates patients and families, addresses psychosocial and social determinants of health barriers, and collaborates with Utilization Management regarding level of care considerations. Serves as the central communicator to promote collaboration, continuity, and achievement of defined outcomes such as reduced readmissions and optimized length of stay.
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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.
Care Coordination and Discharge Planning
Screens and assesses patients to identify clinical, psychosocial,
financial and legal concerns that affect recovery and transition
needs
• Prioritizes patients for care coordination using screening tools.
• Develops and coordinates an individualized plan of care
• Supports interdisciplinary care rounds and documents the plan in
the medical record
• Collaborates with patients, families, providers, nursing, social
work, payers, and agencies to eliminate barriers, arrange services,
and execute safe transitions across levels and locations of care
• Coordinates access to post-acute resources including home care,
equipment, medications, therapies and follow-up appointments
• Provides thorough handoff to the next care team
• Monitors progression of care, avoidable days and length of stay
targets
• Escalates issues that may result in failed discharge or readmission
• Maintains thorough and timely documentation of assessments,
plans and interventions to ensure continuity and regulatory
compliance
Regulatory Compliance
Administers and/or delegates administration of Medicare notices
per regulatory guidelines.
• Collaborates with Utilization Management specialists
• Coordinates pre-authorization for diagnostic tests, procedures and
treatments with payers
• Communicates Utilization Management determinations impacting
discharge planning and resource utilization with the care team.
• Functions as a resource for external agencies requiring clinical
review of patient conditions and carE
Patient and Family Education
Assesses patient and family learning needs and readiness
• Formulates and updates individualized teaching plans in
coordination with the care team and evaluates outcomes
• Facilitates education regarding disease process, treatment plan,
medications and self-management; empowers patients and
families to utilize healthcare resources appropriately
• Provides ongoing education throughout hospitalization and
transition, reinforcing discharge instructions and coordinating
community resources to support continuity of care
• Acts as a clinical resource and mentor to staff on care coordination
practices, criteria application and documentation standards
Quality of Care and Performance Improvement
Monitors readmissions, length of stay, avoidable days and other
indicators
• Identifies trends and implements improvement opportunities with
multidisciplinary partners
• Performs quality data collection and reporting as assigned
• Supports development of policies and forms to meet regulatory
and documentation requirements
• Engages in process improvement initiatives to enhance patient
flow, effectiveness of care coordination and transitions of care
• Supports and coaches accurate clinical documentation by
physicians and the healthcare team to optimize outcomes and
compliance
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