Summary: Coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their provider. Facilitate a shared goal model within and across settings to achieve coordinated high-quality care that is patient centered and family-centered. Major Tasks, Duties, and Responsibilities:
- Implement an effective internal tracking system for identified patients.
- Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care for discharge to next level of care.
- Assess patient and family's unmet health and social needs.
- Provide effective communications to improve health literacy.
- Develop a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
- Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
- Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
- Develop systems to prevent errors (e.g., shared medical records to maintain continuity of care).
- Attend and actively participate in all Care Coordination related training and meeting activities.
- Remain current on Federal and State rules and regulations and policy and procedures.
- Consult with providers regarding patient's level of care as needed.
- Mobilizes meetings, resources, and interviews, as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe.
- Communicates with providers at regular intervals throughout hospitalization and develops an effective working relationship. Assist providers to maintain appropriate desired patient outcomes.
- Complete assessment of patient and family needs at time of admission and reevaluate for any further needs prior to discharge.
- Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family with education, and identified post-hospital needs.
Skills, Education and Experience:
- Previous experience in caring for chronic disease patients.
- 3-5 years of experience in clinical or community health settings.
- Previous Care Coordination, Case Management or Home Health experience.
- Must hold a current RN license in the state of Iowa.
- Previous experience with health IT systems and data reports.
- Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations.
- Ability to speak a relevant second language preferred.
We are now offering a Clinical Recruiting Bonus of $10,000 dollars for new employees! Rehires are not eligible for this bonus. This bonus will be paid out over four years. You will remain eligible for payments after hire so long as there is no drop below full-time in employment status. Each payout is forgiven on the anniversary date that it is paid, giving you the freedom to earn as much or as little as you would like! This is our way of thanking you for choosing Greater Regional Health, and we hope you continue choosing us! The bonus will be paid out as follows: 6 -month anniversary$2,000.00 1- year anniversary$2,000.00 2- year anniversary$2,000.00 3-year anniversary$2,000.00 4-year anniversary$2,000.00 For the 7th year in a row, Greater Regional has been named one of the Top 50 Workplaces in Iowa, which we credit to our employees shared cultural values. We are also proud to announce Greater Regional is one of the Top 100 Critical Access Hospitals in the nation 6 years running. Greater Regional offers an outstanding benefits package to all full-time employees which includes IPERS, tuition reimbursement, wellness screenings, wellness reimbursements, and more. Patients have a choice in health care, they choose Greater Regional Health. You have a choice in employment, choose Greater Regional Health! Apply online or call Jade Wilbourne at 641-###-#### if you have questions regarding your application. ***In order for current employees to be eligible to receive a referral bonus, the applicant cannot have worked at GRH previously and the applicant must include the full name of a current GRH employee on their UKG application in the blank provided. New hires must be hired for a regular, non-casual position to be eligible for bonus. New hires must not drop status for two years after hire for referring employee to get the full bonus. Managers will not be eligible if referring a new team member to their respective department.***