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RN Skilled-Post Acute Case Manager
4 months ago
Overview:
Sign-On Bonus:
$10,000 for qualifying applicants
This position is responsible for design, deployment and general oversight of selected Skilled Nursing beneficiaries who choose one of our preferred network skilled nursing facilities (SNFs) for post-acute care from the time of identification until the patient is transitioned from skilled Part A coverage.
Core responsibilities have a large focus on patient engagement in plan of care, readmission prevention, length of stay management, resource management, and patient experience, keeping care in the system and transition management.
This position uses the nursing process to coordinate the delivery of care, including assessment, planning, implementation, and evaluation of outcomes over the transition and adjustment period for patients discharged from the hospital to area SNFs.
This position must be able to establish relationships and actively collaborates with members of the healthcare team, including hospital staff, SNF administration, staff, Advanced Practice Providers, and Physicians aimed at improving triple aim outcomes.
Works with external skilled facilities to provide on-sight of UnityPoint ACO and Medicare care assigned beneficiaries and vulnerable patients. This position is responsible to design and implement care transition needs including advanced care planning.Why UnityPoint Health?
Commitment to our Team – We've been named a by Becker's Healthcare for our commitment to our team members.
Culture – At UnityPoint Health, you Come for a fulfilling career and experience guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
Benefits – Our competitive program offers benefits options that align with your needs and priorities, no matter what life stage you're in.
Diversity, Equity and Inclusion Commitment – We're committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.
Visit us at (url removed)/careers to hear more from our team members about why UnityPoint Health is a great place to work.
Responsibilities:
Accountable for development, presentation, management, quality improvement action plan and oversight of SNF preferred triple aim goals deployment and results and SNF Network
Leads and coordinates day-to-day SNF network transitions program operations.
Liaison for work of staff performing SNF transitions work.
Attends rounds on patients at SNF as able and applicable for Part A episode duration.
Participates in care planning meetings to assist in comprehensive management of triple aim goals incorporating both the medical and psychosocial needs of the patient in discussions.
Participates in Medicare A meetings to facilitate and engage SNF staff to ensure all recommended patient care, including attainable patient goals, is continued in the SNF setting.
Serves as a patient advocate working closely with the team of providers and patient support systems to connect patients with needed services throughout the continuum.
Monitors various metrics and milestones to assist in appropriate length of stay and other utilization to ensure timely transitions and stewardship in continuum of care.
Collaborates with interdisciplinary team to ensure readmission reviews are completed and measures to mitigate are planned.
Ensures patient receives education and resource materials related to the self-management of disease state.
Ensures standardized processes are established in SNFs for patients who are targeted for discharge home post SNF have 7-day follow up visit to re-establish appointment with primary care provider and Home Health Services set up if indicated.
Serves as the point of contact for coordinating quality improvement processes for the care of patients receiving Medicare A services at Skilled Nursing Facility.
Reviews and prepares reports to monitor program outcomes as assigned. Shares outcome data with key stakeholders.
Designs and Implements Care Transition Needs
Implement and facilitates process for post discharge calls to high-risk patients and rising risk as needed.
Facilitates completion of advanced care planning.
Recognizes and facilitates consultations and or conversations for Palliative Care and Hospice as appropriate.
Basic UPH Performance Criteria
Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
Employee maintains current licenses and/or certifications required for the position.
Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
Completes all annual education and competency requirements within the calendar year.
Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g., Medicare and Medicaid) regarding fraud, waste, and abuse.
Qualifications:
Minimum Requirements
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
Education:
Bachelor of Science (BSN) degree in Nursing
Experience:
- At least 2 years of experience in/with acute care with case management or post-acute care experience.
- 3+ years of experience in/with acute care with case management or post-acute care experience desired.
- Experience in insurance industry related to medical necessity criteria in the acute and post-acute settings.
License(s)/Certification(s):
- Current licensure in good standing to practice as a Registered Nurse in Iowa.
- Valid driver's license when driving any vehicle for work-related reasons.
Knowledge/Skills/Abilities:
- Required English Skills
o Advanced writing skills
o Advanced oral skills
- Communication Skills
o Interaction with a wide variety of people
o Maintain confidential information.
o Ability to communicate only the facts to recipients or to decline to reveal information.
o Ability to project a professional, friendly, helpful demeanor.
- Computer Skills
o Intermediate computer knowledge:
Ability to troubleshoot minor problems within a Windows OS, operates within a network environment, uses spreadsheet, database, word processing and internet applications proficiently.
Learns new applications without difficulty and is able to aid others in immediate work area with computer questions.o E-mail client
Other:
- Use of usual and customary equipment used to perform essential functions of the position.
- Work may occasionally require travel to other UPH facilities/hospitals.
- Required to drive your own vehicle for business purposes.
