Care Transition Specialist

• Area of Interest: Nursing

• FTE/Hours per pay period: 0.8

• Department: Call Center

• Shift: 32 Hours/week - Monday-Friday 8AM-4:30PM + holiday/weekend rotation

• Job ID: 185798

Overview

UntiyPoint Clinic - Transitions of Care

RN Care Coordinator

Waterloo, IA 32 hours/week

Monday-Friday 8AM-4:30PM + holiday/weekend rotation

Full-time benefits offered

*This position is a work-from-home role. This person needs to sit near Sioux City/Fort Dodge/Central Iowa/Cedar Rapids/Waterloo/Cedar Falls, IOWA OR In/around the Quad Cities!

As an RN Care Coordinator – Transition Care, you’ll play an important role in helping patients successfully transition from one healthcare setting to the next—most often from the hospital back home. As part of a collaborative, centralized team, you’ll use your nursing expertise to identify patient needs, coordinate services, and help ensure patients have the support and resources needed for a safe and successful recovery.

You’ll provide telephonic care coordination, complete medication reconciliation and assessments, connect patients with appropriate resources, and provide education to promote better health outcomes. If you enjoy building relationships, coordinating care, and making a meaningful difference in patients’ lives, this is an opportunity to make an impact beyond the traditional clinic setting.

Why UnityPoint Health?

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.

Responsibilities

• Conduct post-discharge outreach and assessments to support patients transitioning home.

• Identify patient needs and provide education, resources, and follow-up to promote successful recovery.

• Complete medication reconciliation and provide education on medications and chronic disease management.

• Help patients understand where to go for care and identify opportunities to prevent unnecessary ED visits and hospitalizations.

• Collaborate with providers and care teams to determine appropriate referrals and services, including Care Management, Home Health, Hospice, and community resources.

• Document assessments, outreach, and care coordination activities accurately and timely in the EMR.

• Serve as a clinical resource and collaborate across departments to support continuity of care.

• Support clinic operations through cross-training in triage and other patient care needs as volume and staffing require.

• Participate in process improvement and strategic initiatives that enhance patient care and support organizational goals.

• Promote clinical excellence through collaboration, professional development, sound clinical judgment, and a commitment to continuous improvement.

Qualifications

• Registered Nurse (RN) – Active/Unencumbered RN license in state of practice or compact license including state of practice.

• 1–2 years of clinical experience in home care and/or ambulatory care.

• Prior experience in a clinical or outpatient setting preferred

• Familiarity with EPIC a plus!