UnityPoint-St Luke's

Full-Time Days

M-F 8am-4:30pm

Creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Utilizes resources to reduce risk while serving as an ambassador between the hospital and community. Performs admission assessment, screening for appropriateness, and monitoring of plan of care to address physical and psychosocial needs, and provides problem solving assistance. Coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Responsible for reviewing and updating plan of care with the healthcare team when applicable. Assesses, monitors, analyzes, and documents resources utilized in the provision of patient care. Promotes communication and collaboration among all members of the healthcare team to ensure that specific outcomes are achieved and variances from accepted parameters are evaluated and addressed as needed.

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.

Care Coordination

• Provides skilled intervention for advocacy and facilitation necessitated by life-changing events i.e. adoption, placement, bereavement, abuse, and guardianship, and mediation of risk factors and coping with disease or disability
• Provides care coordination and discharge planning services to assure that the patient progresses through the continuum of care and has resources in place for community support
• Coordinates the integration of care coordination functions into patient care, discharge, and transition planning processes with the healthcare team, external service organizations, agencies and healthcare facilities
• Provides information regarding internal and external resources and services to patients and/or families as well as the healthcare team
• Coordinates and facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target LOS
• Completes and documents assigned quality audits and avoidable day reporting
• Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds
• Engages in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided Completes all necessary paperwork to facilitate the patient's transition through all levels of care and provides communication between community resources and the patient and/or family

Assessment/Planning

• Assesses all assigned patients in person and integrates family information to determine potential and actual risks to recovery and the next level of care needed
• Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record
• Provides skilled intervention for the support and/or resolution of patient and family crises, problem solving, and decision making
• Improves patient and/or family understanding of and adjustment to the medical diagnosis and plan of care
• Uses established protocols to assess and promptly documents the patient’s health care needs to assure an accurate legal record of patient’s care Identifies the need for and conducts family/team meetings that result in comfort, decisions, goal attainment, and other important outcomes

Relationship Building

• Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting
• Coordinates and facilitates patient centered interdisciplinary care and communication, ensuring progress toward goal attainment
• Supports and coaches accurate clinical documentation by physicians and other healthcare team members Builds a network of positive working relationships that advocate for the patient

• Education: Master’s degree in Social Work or related field required.
• Experience: 3 to 5 years clinical experience as a social worker, with at least 1 year working with the diagnostic population to which the care coordinator will be assigned required.
• License/Certifications: Master of Social Work or related field required.  Valid driver’s license when driving any vehicle for work-related reasons.
• Knowledge/Skills/Abilities: Excellent communication skills, particularly in face-to-face personal contact with patients and families. Critical thinking and problem solving skills and coping effectively with stressful situations. Must possess time management skills Knowledge of social services in a health care setting, including crisis intervention, support counseling and discharge planning Understand the concepts of levels of care, payment systems and insurance requirements Working knowledge of community information and resources for referrals Knowledge and skills necessary to provide services/care appropriate to the age and diagnosis of patients served across the continuum of care, in accordance with the hospital/departmental/unit standards Maintain working knowledge of applicable Federal, State, and local laws and regulations as well as other policies and procedures in order to ensure adherence in a manner that reflects honest and professional behavior Discretion in handling highly confidential information from patients and ability to work with highly diverse populations
• Other: Use of usual and customary equipment used to perform essential functions of the position.