Inpatient Care Navigator

2 weeks ago


Des Moines Iowa, United States UnityPoint Health Full time

Overview:
Inpatient Care Navigator - Younker 7 and Younker 8 - Iowa Methodist

Full-Time, 40 hours per week

Shift:
Monday-Friday, 8am-4:30pm

Benefits Eligible

The Care Navigator plays a crucial role in integrating and coordinating the clinical care of patients.

Facilitates the interdisciplinary care plan to address various service needs, ensuring continuity of care and optimizing resource utilization.

Acts as an educator and a primary communication source for patients and their support networks.

Why UnityPoint Health?


Commitment to our Team – Recognized for our dedication to team members.

Culture – At UnityPoint Health, your contributions are valued.

Join us for a rewarding career grounded in our core values and a steadfast commitment to serving our community.


Benefits – Our comprehensive Total Rewards program offers a variety of benefits tailored to your needs and priorities.


Diversity, Equity, and Inclusion Commitment – We are dedicated to ensuring every voice is heard, regardless of role, race, gender, religion, or sexual orientation.

Development – We believe in providing support and resources as essential components of a remarkable employment experience.


Community Involvement – Be a vital part of our mission to enhance the health of the individuals and communities we serve.



Responsibilities:
Key Accountability—Care Coordination


Conducts assessments of all adult Medical Surgical in-patients and observation patients, evaluating their health status, support systems, and resource needs to facilitate appropriate referrals to multidisciplinary services.

Prioritizes patients for care coordination based on established criteria.


Monitors and collaborates on an interdisciplinary care plan in partnership with patients and their support systems to address needs across the healthcare continuum and ensure smooth transitions between care levels.

Takes responsibility for developing and executing effective discharge plans for complex care patients.

Collaborates with internal and external resources to ensure timely and safe transitions to the appropriate level of care.


Participates with the interdisciplinary team in daily rounds, planning, delivering, and evaluating patient-centered care for prioritized patients.


Documents the care management plan, including clinical needs, barriers to quality care, and effective resource utilization, while addressing payment denials and referrals promptly.

Ensures tighter integration with the ambulatory care management team, particularly for high-risk, chronically ill patients.
Standardizes alerts to cross-continuum care managers when patients are admitted.

Works closely with providers for discharge planning and determining the next level of care.

Collaborates with patients, caregivers, internal/external healthcare providers, agencies, and payers to plan and execute safe discharges.

Partners with the Utilization Management team on continued stay reviews.

Key Accountability - Discharge Planning

Collaborates with patients, caregivers, internal/external healthcare providers, agencies, and payers to plan and execute safe discharges.


Identifies and facilitates post-acute resource needs, including Home Care, Community-based Referrals, Diagnostic Testing, Outpatient Therapies (Pulmonary Rehab, Cardiac Rehab, Physical and/or Occupational Therapy), Palliative Care, or Hospice.

Ensures the patient's vulnerability level is documented on the Transitions of Care report.


Communicates verbally with the ambulatory/cross-continuum care manager regarding patients with moderate or high vulnerability at transition.


Documents who will take on the care coordination/management role for these patients and for what duration in the Common Care Plan and the Transition of Care report, if known.

Reviews predictive tools for readmission and documents the associated risks. Implements additional interventions to mitigate readmission risks, such as scheduling follow-up appointments at critical times.

Facilitates reconciliation of discharge medication orders and alerts primary care staff to any formulary changes.

Utilizes the med-to-bed program for patients with multiple medications.

Key Accountability - Education

Optimizes the use of Healthwise for Patient Education.

Communicates patient/family learning needs to the direct care nurse and collaborates on the education plan.

Refers to content experts as needed, such as wound care teams, Diabetic Educators, Respiratory Therapy, or Physical Therapy.

Documents education related to medication adherence.

Facilitates patient self-management education.

Key Accountability—Revenue Cycle


Demonstrates knowledge of financial and reimbursement processes to aid in medical cost management, including best practices, effective resource utilization, and linking clinical and financial aspects of care.


Serves as a resource and educator for patients, families, staff, and physicians regarding financial aspects that may influence patient transitions through the healthcare system.


Provides education for individuals and families, as well as for the team, regarding benefits, resource utilization, levels of care, and expectations during the transition process across various healthcare settings.

Empowers patients and families in self-management and healthcare decision-making.

Qualifications:

Education:
Bachelor's degree in a healthcare-related field or BSN preferred.

Experience:
Two years of clinical experience in relevant areas working with multidisciplinary teams.

License(s)/Certification(s):
Current RN Licensure in the state of residence.

Knowledge/Skills/Abilities:
Fluent in reading, writing, and speaking English.

Basic computer skills, including word processing, spreadsheets, email, and web browsing.

Other:
Utilization of standard equipment necessary to perform essential functions of the position.
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